health plans emerging as pragmatic partners in fight ... · figure 5. trend in bariatric surgery...

Health Plans Emerging As Pragmatic Partners in Fight Against Obesity

REPORT • APRIL 2005

TABLE OF CONTENTS

Executive Summary 1

Introduction 2

Report Findings 3

Plan Profiles

Aetna 12

Affinity Health Plan 13

Blue Cross Blue Shield of Massachussets 16

Blue Cross and Blue Shield of North Carolina 18

Empire Blue Cross Blue Shield 22

HealthPartners 25

Highmark, Inc. 28

Horizon Blue Cross Blue Shield 31

Kaiser Permanente 34

Premera Blue Cross 37

WellPoint Health Networks 41

Guest Essays

William H. Dietz, MD, MPH 44

Kenneth R. Melani, MD 45

David Katz, MD, MPH 46

Eric J. Berman, DO, MS 47

Helen Darling 48

George Isham, MD 49

Robert F. Kushner, MD 50

Tables and Figures

Table 1. World Health Organization Obesity Definitions for Adults 3

Figure 1. Changes in the Prevalence of Obesity (1987-2001) 3

Figure 2. Annual Cost of Medical Care ServicesRelative to Weight Categories (1990-1998) 3

Figure 3. Matrix of Health Plan Initiatives 8

Figure 4. Global Sales of Anti-Obesity Drugs (1992-2011) 23

Figure 5. Trend in Bariatric Surgery Use (1992-2003) 32

Table 2. Recommendations for Promoting Physical Activity 40

Sidebar Discussions

Medicare and Medicaid – Major Insurers with Major Roles 15

Obesity-Related Prescription Drug Treatments 23

Employers and Health Plans Weigh Benefits andRisks of Weight Loss Surgery 32

Expert Panel’s Recommendations Set Important Standards 39

EXECUTIVE SUMMARY

The physical cause of obesity is simple. Calories taken in exceed calories expended.However, an effective response to the obesity epidemic is not so simple. It requires anunderstanding of a variety of complex and interrelated contributing factors. As obesity in America has reached epidemic proportions, it has prompted the need for realtime responses guided by information about what obesity prevention and weight reductionstrategies work for distinct subgroups of the population. In general, we know that the beststrategy for combating obesity is a multifaceted one involving the efforts of manystakeholders, including individuals, families, employers, health plans, schools and govern-ment. Though the need for partnerships is clear, the evidence base supporting specific strategies requires further research to develop a more solid basis for action.

In this NIHCM Foundation report, we focus on the emerging role of health plans in thefight against obesity. We profile a cross section of 11 large health plans and find numer-ous examples of active partnerships with other stakeholders. Health plans are emergingas partners in the fight against the obesity epidemic by:

n Educating providers about screening for obesity in children, n Creating incentives for plan members to participate in weight loss programs,n Covering weight loss drugs and surgical treatment when necessary,n Sponsoring worksite programs,n Encouraging physical activity in schools, andn Creating and funding community-based weight management programs.

In many cases plans are evaluating these strategies to develop better ways to combatthis epidemic. This is an important role for plans because they have the ability to collectdata on populations over a long time period in order to evaluate the long-term effects ofdifferent obesity prevention and reduction and weight management strategies. Conductingsuch analyses is in the interest of all stakeholders and society at large.

For this NIHCM Foundation report, we also solicited perspectives from seven of the nation’sprominent health care leaders on how to combat the epidemic of overweight and obesity.Their essays, included at the end of this report, reflect a range of points of view. However,all agree that health plans alone cannot solve the obesity problem, nor can any singlestrategy or program. From this body of expert opinion, we draw five main themes neededin a national strategy for combating obesity:

n A range of specific actions that can be taken immediately (such as use of body massindex [BMI] or related measures as a vital sign),

n Evidence of effectiveness,n New models of care, moving away from acute treatment to prevention and chronic care,n Coordination of public and private resources, andn Cultural change.

EXECUTIVE SUMMARY 1

2 HEALTH PLANS EMERGING AS PRAGMATIC PARTNERS IN FIGHT AGAINST OBESITY

INTRODUCTION

The purpose of this report is to describe the activities of adiverse national sample of leading health plans to combatthe obesity epidemic. The report features innovative,forward-thinking strategies that are already in place orare nearing implementation at 11 health plans across thecountry. It also features essays by seven leading experts,representing a range of stakeholders in the fight againstobesity, who present their views on what can and shouldbe done — not just what is being done — to combat obesity.

In this introduction, we include a brief description of theobesity problem in this country — a crisis of epidemic pro-portions that has attracted considerable media attention.Next, we summarize key themes that emerge among ourguest essayists about what should be done to combat theobesity epidemic, provide illustrations of current planpractices that implement or approach these ideals, andidentify gaps between what is being done and what couldbe done. Finally, we provide an overview of the healthplan interventions featured in the body of the report, whichwe broadly classify as childhood, adult and community-based programs.

Obesity has Reached Epidemic Proportions inthe United States

Facts about the growing obesity epidemic in the UnitedStates feature prominently in the media and in medicaland health policy journals, but repetition has not dimin-ished their “shock value":

n Nearly two-thirds of the adult population is over-weight and 30 percent of this number are obese. Theprevalence of adult obesity has doubled over the last20 years.1

n Fifteen (15) percent of children and adolescents are over-weight and another 15 percent are at risk of becomingoverweight.2 Seventy (70) to 80 percent of obese ado-lescents will become obese adults.3

n Among adults, the impact of being obese on healthstatus is equivalent to aging 20 years.4

n Overweight adults have a 60 percent increased risk ofdiabetes, an 80 percent increased risk of high bloodpressure, and a 50 percent higher likelihood of elevatedcholesterol levels. For those with moderate obesity, the

risk of diabetes or high blood pressure is increased morethan threefold, and the likelihood of a high bloodcholesterol level or arthritis doubles.5

n The percent of children and adults who are overweightor obese is growing at an alarming rate (see Figure 1).

The economic consequences of the nation’s obesity epidemicare substantial:

n On average, health care costs for obese Americans are36 percent higher than for people of normal weight(See Figure 2).6

n Estimates of the total direct and indirect costs attrib-uted to obesity vary but may be as high as $117 billionannually.7

n Obesity accounted for between 5 and 9 percent oftotal health care expenditures in 1998 and accountedfor more than 25 percent of the increase in health carecosts between 1987 and 2001.8,9

The nation’s obesity epidemic is the result of numerouscomplex and intertwined factors, including: diet, seden-tary lifestyles, genetics, community planning, stressfulwork schedules, low literacy, cultural issues, resistance tochange practice patterns within the health care providercommunity, the availability of relatively few medical inter-ventions, and competition for scarce public dollars. Thecomplexity of the problem requires solutions that go farbeyond the medical. Indeed, only a broad public healthapproach — one that brings together all levels of govern-ment, medical and public health researchers, health careproviders, health plans, and individual communities — willbe successful.

The focus of this report is largely on health plans, whichhave a critical role to play in combating the obesity epi-demic, both in the development of their own programsand in working cooperatively with other stakeholders.

INTRODUCTION 3

Report Findings

Guest Essays: Key Themes for Success

The NIHCM Foundation invited seven prominent healthcare leaders to write about the obesity problem. Theresulting collection of essays represents the views of across-section of stakeholders, including representatives ofhealth plans, government, providers, employers andacademia. They present a wide range of viewpoints andinsights on this complex issue and highlight what needsto be done to initiate effective, comprehensive programsfor prevention and treatment.

The health plans featured in this report have emerged aspragmatic partners in addressing obesity and will likelycontinue to do so as evidence of effectiveness builds andcommunity partnerships demonstrate success. The urgentneed to prevent and reduce obesity is leading healthplans to rethink old strategies — for example, by shiftingfrom acute treatments like drugs and surgery to chroniccare management, weight management programs, andpartnerships within the community. Some health planshave begun to implement specific measures that can havean immediate impact, such as encouraging the use ofBody Mass Index (BMI) as a vital sign and educatingproviders on weight management counseling strategies.However, experts agree that effectively managing theobesity problem will require significant cultural changes,which are beyond the reach of health plans alone.Clearly, providers, payers and communities also haveimportant roles to play — independently and in collabora-tion with other stakeholders.

In the essays written for this report, we found that sever-al common themes emerged from our guest essayists. Welist these themes below and briefly illustrate them withexisting interventions that we describe in detail in theplan profile section of the report (beginning on page 11.)

n First, and perhaps most broadly, our society as awhole must undergo cultural change to promotehealthy lifestyles. We should increase our physicalactivity and improve our nutrition, and parents shouldmodel this behavior for their children. Our schoolsshould provide healthy food options for children, andour buildings and communities should encouragephysical activity.

Many of the plans featured in this report are activelyengaged in community-based efforts to promotehealthy lifestyles. For example, Highmark works with

Figure 2. Annual Cost of Medical Care Services Relative to Weight Categories (1990-1998)

Figure 1. Changes in the Prevalence of Obesity (1987-2001)

Annual Cost (1998 dollars)

Pharmacy InpatientType of Service

Total$0

$500

$1,000

$1,500

$2,000

Normal Weight

Overweight

Obese

Table 1. World Health Organization Obesity Definitions for Adults

Category Body Mass Index (BMI)

Ideal Weight 20-24.9Overweight 25-29.9Moderate Obesity 30-34.9Severe Obesity 35-39.9Morbid Obesity 40-49.9Super Obesity >50

Precent of Population

Year

1987 20010

10

20

30

40

50

38.635.7

Normal Weight 51.6

Overweight 31.3

Obese 13.5

Underweight 3.6

23.8

1.9

Source: Thompson D et al. "Body Mass Index and Future Healthcare Costs: A Retrospective Cohort Study" Obesity Research 9(3):210-218.

Source: Thorpe K et al. "The Impact of Obesity on Rising Medical Spending"Health Affairs Web Exclusive W4-480; October 20, 2004.

n Third, the obesity epidemic requires a new model of careinvolving a shift from treatment of acute conditions toprevention and chronic care. This new model utilizeselectronic health records for better care management andempowers individuals and families to manage theirhealth. It also involves non-traditional providers likenutritionists and social workers in care delivery.Moreover, the model also looks to the environment, suchas schools, the workplace, and communities, as potentialsources of change to improve the nation’s health.

The plans profiled in this report have developed a varietyof educational tools to educate providers and members.Empire Blue Cross Blue Shield has established a 360ºHealth program that makes available numerous educa-tional tools to address weight management across itsmembership. The plan has dedicated a department staffedwith clinical personnel, registered nurses (RNs), and regis-tered dieticians, who are focused on enhanced awarenessand behavior modification through member health educa-tion. WellPoint has established health improvement pro-grams led by health coaches that include RNs, dieticians,social workers, exercise physiologists and other healthprofessionals. Premera has formed a Comprehensive ObesityStrategy Team to define, develop and implement a weightmanagement strategy for members and employers. Theteam designed a five-tier program to balance coveragewith choice. In many of the ways mentioned above, otherplans, including Horizon, Aetna and Affinity are movingtoward a new model of care that helps individuals bettermanage their own health.

n Fourth, the evidence of effectiveness of specific weightreduction and management initiatives must be demon-strated to motivate health plans and other stakeholders toaddress this issue broadly, especially in view of the private,employer-based health care system and the mobility ofthe American worker. Through research and evaluation ofprogram effectiveness, government and health plans cansupport evidence-based initiatives that improve memberand community health, are cost-effective, and ultimatelygenerate a return on investment.

Many of the plans profiled in this report are adding tothe evidence base on effective interventions. For exam-ple, Highmark is currently conducting an independentevaluation of a nationally recognized pediatric weightmanagement program, KidShape®. Blue Cross and BlueShield of North Carolina is evaluating the success of itsHealthy Lifestyle ChoicesSM program. Empire Blue Cross


numerous community partners and provides substan-tial funding to schools to introduce nutritional cur-ricula and physical activity programs. Highmark alsooffers the KidShape® program, a nationally recognizedpediatric weight management program targetingoverweight children and teens and their parents, inits service region. Horizon has launched employeewellness programs in Southern New Jersey and hastaken a leadership role in focusing the state’s healthpolicy agenda on the growing obesity epidemic.Premera has joined with Microsoft to offer a compre-hensive weight management program for plan partic-ipants and Microsoft employees. Blue Cross BlueShield of Massachusetts’ Healthy Choices programprovided grants to a third of Massachusetts middleschools last year to implement an interdisciplinarycurriculum focused on nutrition and physical activity.

n Second, we must coordinate public and private sec-tor resources to communicate the dangerous medicalconsequences of obesity. Health plans can lead thiseffort by initiating collaborative educational activities.Also, public and private payers can create economicincentives to encourage providers to educate patients,and for members to participate in weight manage-ment programs and engage in healthy lifestyles. Thefederal government can help identify evidence-basedstrategies for implementers, and local and stategovernments can work in collaboration with schoolsand other organizations interested in combating theobesity epidemic.

Blue Cross and Blue Shield of North Carolina, throughcorporate contributions and the BCBSNC Foundation,supports a number of community-based initiatives, suchas the Kids Café Program, Be Active North Carolina, Inc.,and Fit Together. Horizon’s co-sponsored community-based programs include the following: a youth mentoringprogram, the Shape It Up Program, the Horizon Walksfor Health Campaign, the Horizon Health Kit, and HorizonHealth Future. WellPoint has collaborated with theAmerican Dietetic Association to develop a bilingualprint and web-based guide called Healthy Habits forHealthy Kids, which provides practical strategies forengaging families in healthy eating and physical activity.Kaiser Permanente and HealthPartners have coordinatedwith the Centers for Disease Control and Prevention totranslate and disseminate evidence-based recommenda-tions for weight management and the prevention andreduction of obesity.

Blue Shield is evaluating its pilot program, TheHealthy Weigh to Change, which is based on theBCBS Walking WorksSM program. HealthPartners alsohas evaluations underway in the areas of adolescentobesity and weight maintenance for adults.

n Fifth, there are specific actions that can be takenimmediately to address obesity. The adoption of BMIas a vital sign, more and better education of providerson obesity treatment and prevention options, and tight-ened criteria for bariatric surgery and weight loss drugsare some first steps that the health community couldtake toward effective care.

WellPoint has collaborated with a number of partnersto develop a web-based continuing medical eduction(CME) program to provide health care practitionerswith the knowledge, attitudes and skills necessary tohelp them detect, assess and manage overweight andobese children and adolescents. Blue Cross and BlueShield of North Carolina is also implementing pro-grams to help pediatric providers better recognize,counsel and treat patients who are overweight or at-risk. Kaiser Permanente has begun to implement anaggressive effort to collect BMI as a vital sign.

Plan Profiles: Summary of Interventions

The health plans profiled in this report have developed avariety of obesity prevention and reduction initiatives thatare consistent with the themes expressed by our guestessayists. These plans grasp the enormity of the obesityproblem and the need to act before “gold standard” evi-dence emerges on the most effective treatments for vari-ous groups. Their initiatives span an array of interventionsand partnerships that can serve as models for other healthplans looking to combat obesity in their communities.

Approach

The NIHCM Foundation selected health plans to be featuredin this report that are leaders in the fight against obesity.We identified plans that are broadly representative —insize, geography and populations served — of the industry.We conducted an “environmental scan" that includedreviews of the literature and the popular press, discus-sions with industry and obesity experts, and “word ofmouth" referrals. Information for the plan profiles was

INTRODUCTION 5

gathered through a series of interviews with plan repre-sentatives, as well as a review of documentation related tothe plans’ obesity efforts.

Some of the plans profiled in this report were chosenbecause they are applying and testing the latest evidence-based approaches to obesity and weight management foradults, children, and adolescents. Other plans were chosenbecause they are leaders in their communities in raisingawareness about the issue of obesity through educationalprograms, grants, and participation in the public policyprocess. By highlighting health plans with innovative obe-sity programs, these new approaches and successful inter-ventions can be shared and modeled among other healthplans eager to address obesity in their communities.

Organizing Framework

For simplicity, we have organized health plan interventionsinto three categories: childhood obesity programs, programsfor adult members, and community-based initiatives.Interventions are broadly classified and summarized inFigure 3 on pages 8 and 9. It should be noted, however,that many of the plans featured in this report have pro-grams in place that fall into two or even all three of thesecategories. We present individual plan profiles in this reportin alphabetical order, with childhood, adult, and communi-ty-based efforts highlighted in each profile.

Programs for Children

Many feel that preventing and reducing childhood obesityis the greatest national public health challenge as well asthe greatest opportunity for health plans, providers, andsociety at large. Nearly a third of American children areoverweight or obese, and the long-term consequences forthe public’s health, health care costs, and demand on thehealth care system are significant. Overweight children areat substantially greater risk for developing serious condi-tions, including diabetes, heart disease, and certain types ofcancer. As Dr. Kenneth Melani, President and CEO ofHighmark, Inc., notes in his essay, “In addition to the pricethese children eventually will pay in terms of their health,there also will be a substantial financial price to be paid—a price the nation simply may not be able to afford."

There are various complicating factors that make treatmentand prevention of childhood obesity even more difficult


than in adults. Pediatric providers are beginning to seeobesity-related conditions that had until recently beenseen only by adult medicine providers. In addition, theteasing and bullying so common among children can beparticularly devastating for a child who is battling aweight problem.

Because the behaviors of children, including those related todiet and physical activity, are heavily influenced by theirparents and other family members, the country has atremendous opportunity to head off the debilitating con-sequences of obesity through education, awareness andprevention efforts aimed at children and their families.

Physician Tools and ResourcesDr. Robert Kushner of Northwestern Memorial Hospital’sWellness Institute writes in his essay that physicians are“woefully unprepared" to treat or prevent the underlyingcauses of obesity. Instead, he argues, physicians are trainedto treat the consequences of obesity, such as diabetes andhigh blood pressure. This is particularly true of pediatricprimary care providers, according to a recent survey pub-lished in the journal Pediatrics.10 Several of the plans weprofile have established programs to address this problem.For example, WellPoint is developing a web-based CMEprogram to help providers recognize, prevent, and treatchildhood obesity. Horizon has developed and distributeda web-based pediatric assessment tool to measure over-weight and obesity risk in children. The assessment toolis available to all physicians both inside and outside ofHorizon’s network.

Weight Loss ProgramsSeveral plans profiled herein have developed weight lossprograms specifically designed for children. For exam-ple, Affinity, a Bronx-based health plan that primarilyserves the Medicaid and SCHIP populations, implementeda pediatric obesity pilot program in 2004. The programemploys a multi-disciplinary approach with a specialemphasis on family involvement and focuses on changingunhealthy family behaviors. In addition, Highmark isevaluating a nationally recognized pediatric weight man-agement program at multiple sites in Pennsylvania.During the pilot, the program will be available to bothHighmark members and non-members who meet qualify-ing criteria.

Programs for Adults

Traditionally, insurers have limited obesity-related bene-fits to surgical treatments for the morbidly obese andtreatment of chronic diseases that result from or areexacerbated by obesity. Treatment of obesity in theabsence of co-morbid conditions was generally not reim-bursed by insurers and, as a result, was rarely even codedby providers. However, today, this situation is beginningto change. As an example, Blue Cross Blue Shield ofNorth Carolina recently announced that it would coverup to four office visits for the evaluation and treatmentof obesity.

Increasingly, health plans are developing and implement-ing innovative, evidence-based strategies to prevent andtreat obesity. Some of these programs are relatively new,while others have been in place for several years and aregenerating data that can be used to evaluate relative pro-gram effectiveness.

The adult-focused interventions featured in this reportfall into three broad categories: access to weight losstools and resources, weight loss programs, and weightloss drugs and bariatric surgery. We also describe com-mon problems the plans encountered when implementingtheir programs.

Weight Loss Tools and ResourcesMany of the plans profiled in this report provide members(and sometimes the community at-large) with an array ofeducational resources, including web-based and printedmaterials, to help them make healthy choices and encouragesimple behavioral changes that can improve their overallhealth. For example, WellPoint has developed several printand web-based resources to help families achieve a healthi-er lifestyle. These resources are available in multiple lan-guages, and some are specifically written for a low-literacyaudience. Some plans, such as Aetna and HealthPartners,also provide members with weight management tools,including BMI wheels, pedometers, and daily food andactivity logs. While these resources are but a part of a larg-er obesity strategy, they are an important component, asfamilies depend on their health plan as a source for reliableinformation about improving their health.

Weight Loss ProgramsOne of the adjustments plans are making in addressingthe obesity epidemic is recognizing that solely clinicalinterventions are limited, largely, to the morbidly obese.

quality and outcomes, several plans, including WellPointand Horizon, have identified Centers of Excellence for theirbariatric surgery candidates.

Common BarriersSeveral health plans noted that attrition from weight lossprograms is a common problem. Some are addressingattrition by offering incentives, such as pedometers anddiscounted health club memberships, at various intervalsthroughout the weight loss program. Others are consideringoffering financial incentives for members who successfullycomplete weight loss programs. Empire Blue Cross BlueShield decided to take its weight loss program to theemployer’s worksite to make it easier for members toparticipate. Data—or rather the lack thereof—was alsocited as a barrier by several plans. Providers have not yetwidely adopted BMI as a vital sign, and the health carecommunity is only slowly implementing an electronichealth record (EHR), both of which are hampering effortsaimed at prevention and care coordination. Some plans,such as Kaiser Permanente, have launched aggressiveefforts to implement EHRs and collect BMI for all members.

Community-Based Programs

A common theme expressed by several guest essayists inthis report is the importance of private-public collabora-tion in the battle to combat the obesity epidemic. Thisstrategy dovetails with the generally accepted view that amulti-faceted approach to intervention will have greaterbenefit than pursuing a single strategy. In our review ofhealth plan activities, we found that in addition to imple-menting a range of interventions for their members,health plans have begun to partner with stakeholders inlocal communities to combine their resource base andbroaden the impact of either party individually.

Grants and Community-based Partnerships Many of the plans profiled in this report have activegrant-making programs aimed at supporting healthierschools and communities. Some grant programs help fillfunding voids resulting from cuts to schools’ and parks’budgets. Other plans have established ongoing relation-ships with community-based organizations around sharedgoals. For example, Horizon Blue Cross and Blue Shieldof New Jersey has implemented several programs in con-junction with Boys and Girls Clubs and other community-based organizations to improve health literacy among

Dr. William Dietz of the Centers for Disease Control andPrevention (CDC) notes in his essay that a new model ofobesity care “must move towards helping overweight andobese patients develop the skills for self-management oftheir condition." He adds that care, while overseen byphysicians, will likely be delivered by nutritionists, nursepractitioners, social workers and others trained in behav-ior modification techniques.

Many of the plans profiled have adopted this approach byestablishing multi-session weight loss programs led bymulti-disciplinary teams. The format (individual, group, or acombination of both), means (in-person or telephone based),eligibility criteria(open or limited) and curricula vary, butall emphasize behavior modification and healthy lifestyles.For example, Premera Blue Cross developed a comprehen-sive weight management program for its Microsoft employergroup and will begin offering similar programs as an optionfor others in 2005. Employees who qualify for the Microsoftprogram can enroll in approved medically-supervisedweight management programs that provide a minimum often sessions with a physician, a personal fitness trainer, adietician and a behavioral health therapist.

Weight Loss Drugs and Bariatric Surgery Two of the most controversial strategies to reduce over-weight and obesity are coverage of weight loss drugs andbariatric surgery. While the debate over the efficacy andsafety of weight loss drugs continues, the medical commu-nity is considering a new role for these medications. Whilenot the magic bullet some had hoped for, there is growingevidence that weight loss drugs can play an effective sup-porting role in the treatment of some obese individuals. At present, the evidence on these drugs is far from over-whelming, and variability among health plan coverage poli-cies reflects this lack of consensus. With an average pricetag of $35,000 and somewhat mixed evidence on safetyand long-term benefits, coverage of weight loss surgery isa difficult decision for many health plans. While severallarge plans have recently dropped coverage for weight losssurgery due to high costs and conflicting evidence on safetyand efficacy, most of the plans profiled in this report docover weight loss surgery or at least offer it as a purchasablerider. Among the plans profiled that do offer coverage, allcondition eligibility for the surgery on specific criteria(typically the NIH-recommended criteria of a BMI >40, or a BMI >35 with one or more co-morbid conditions). In addition, many plans require extensive pre- and post-surgical counseling as well as participation in ongoingweight management programs. In an effort to improve

INTRODUCTION 7


Plan Childhood ObesityPrograms

Weight Loss Tools andResources (e.g., web-based information, discounted health clubmemberships, etc.)

Weight Loss/Management Programs

Coverage of ApprovedWeight Loss Drugs

Coverage of BariatricSurgery/Centers ofExcellence (COEs)

Sponsorship ofCommunity-BasedWeight Management/Obesity Programs

Aetna Available to all membersat no additional cost

Pilot program for specificgroups launched 10/04

Telephone counselingavailable to pilot programparticipants

Not covered if sole purpose is weight loss;purchasable as rider

Offered as rider exceptwhere mandated. COEsbeing identified in areaswhere bariatric surgeryis mandated

Affinity Pilot pediatric obesityprogram

Covered, with priorapproval, for non-Medicaid membership

Drugs are carved out ofMedicaid managed care

Covered for membersmeeting criteria

Under development for 2005

BCBSMassachusetts

Community-based programs that targetchildren

Middle School-basedobesity prevention program

Available to all membersat no additional cost

Web Based program

Registered dieticiansavailable to memberswho meet criteria

Disease managementprogram under develop-ment for 2005

Pilot telephonic walkingprogram

$150 benefits for healthclub or Weight WatchersTM

Covered benefit tomembers who meet specific criteria

Covered for membersmeeting criteria. COEsare currently being considered

Several grant programsfor senior fitness programs and youth-serving organizations

Statewide distribution ofa pediatrician tool kit

BCBS NorthCarolina

Community-based pro-grams that target chil-dren


Available to membersmeeting criteria

Covered with priorauthorization


COEs have been designated

Several active partner-ships with communitybased nutrition, fitness,and wellness programs

Empire BCBS In development for2005


Online 4-week programfor members

Pre-recorded telephoneeducational modulesavailable

Worksite pilot programin progress



HealthPartners Community-based programs that targetchildren


Phone-based weightmanagement/diseasemanagement programfor members meetingcriteria; web-based program available to all members

Covered for membersmeeting criteria withprior authorization


COEs have been desig-nated

Partnership with BeActive Minnesota

Highmark Grants for youth nutrition/physical education programs



Personalized web-basedprogram offered to allmembers at no cost

Eat Well for Life weightmanagement/nutritionprogram

Blues on Call telephonehealth coaching program

Covered for underlyingconditions related toobesity


Implementing a nation-ally recognized pediatricweight managementprogram in several communities

Programs for Community-Based Children Programs for Adults Programs

Figure 3. Matrix of Health Plan Initiatives

INTRODUCTION 9

Plan Childhood ObesityPrograms

Weight Loss Tools andResources (e.g., web-based information, discounted health clubmemberships, etc.)

Weight Loss/Management Programs

Coverage of ApprovedWeight Loss Drugs

Coverage of BariatricSurgery/Centers ofExcellence (COEs)

Sponsorship ofCommunity-BasedWeight Management/Obesity Programs

Highmark Grants for youth nutrition/physical education programs



Personalized web-basedprogram offered to allmembers at no cost

Eat Well for Life weightmanagement/nutritionprogram

Blues on Call telephonehealth coaching pro-gram.

Covered for underlyingconditions related toobesity


Implementing a nationally recognizedpediatric weight management program in several communities

Horizon Community-based programs that targetchildren


Discounts for commercialweight loss programsand health clubs underconsideration

Health and WellnessEducation pilot for fullyinsured HMO members

Weigh to Live pilot program

Pilot telephone counseling program inplace for fully insuredHMO members

Covered when prescribedby a physician


COEs have been desig-nated

Developed and sponsornumerous community-based programs, including educationalprograms and health literacy-focused tutoring programs

Kaiser Child/Adolescentweight managementprograms available inmost KP regions


Available in all regions;programs vary by region

Coverage varies by region

Covered for membersmeeting criteria. KP’sgoal is to be a center ofexcellence; currentlyreviewing KP programsagainst criteria

Varies by region, butincludes efforts to workwith community clinicsand other safety netproviders on obesity and other health issues

Premera Available to all membersat no additional cost

Individualized, group-based and obesitydisease managementprograms available aspurchasable options

Telephone counselingprovided throughDisease Managementand Health RiskManagement programs

Not covered Offered as rider

Requires prior authorization

WellPoint CME program on childhood obesity

Educational tools forfamilies and providers


Weight managementintegrated into severaldisease managementprograms

Coverage varies by market

Coverage varies by market

COEs designated inCalifornia and are beingevaluated in Georgia andWisconsin

Programs for Community-Based Children Programs for Adults Programs


children and teens, with a particular emphasis on weightmanagement. Blue Cross and Blue Shield of Massachusettsand Highmark have established grant programs to helpcommunity-based organizations and middle schoolsestablish fitness and nutrition programs.

Influencing Public PolicyIn a recent editorial in The American Journal of ManagedCare, Yale University’s Kelly Brownell writes, “Changingthe environment through public policy may be the mosteffective means of preventing obesity, and such changescould benefit the healthcare system in general and man-aged care organizations in particular."11 Several of theplans profiled in this report are actively engaged at thefederal and state levels in shaping public policy approach-es to overweight and obesity. These efforts aim to bringtogether representatives of health care plans, providers,employers, researchers, the food industry, and policymak-ers to identify short- and long-term policy actions thatmodify social and organizational structures that contributeto the obesity epidemic.

At the state level, Horizon Blue Cross Blue Shield spon-sors an annual Health Policy Forum each October, whichconvenes New Jersey policymakers, clinical experts, andhealth leaders to discuss obesity and health literacy,among other important issues. At the 2004 forum, Horizonlaunched the New Jersey Health Policy Consortium, whichwill bring together diverse expertise and is designed toinfluence the health policy agenda in the state. At thefederal level, Kaiser Permanente’s Care ManagementInstitute sponsored a major national roundtable discussionin 2003 titled “Prevention and Treatment of Overweightand Obesity: Toward a Roadmap for Advocacy and Action,"which gathered together researchers, health plans, andcommunity organizations to discuss public policy inter-ventions. The results were widely disseminated.

Conclusions

Dr. Peter Briss, Chief of the Community Guide Branch atCDC, has suggested several actions that health insurerscould take to help prevent and treat obesity in the U.S.12

According to Dr. Briss, health insurers can be providers ofinformation, creating awareness of the problem in thepopulation and encouraging evidence-based practices inhealth care systems. Health insurers can also encouragereferrals to community-based weight management programs. Health plan partnerships with employers and

other purchasers of health insurance can support healthyworksites and inclusion of obesity prevention and weightmanagement programs in benefits packages. Health planscan work with their own employees to promote physicalactivity, healthy nutrition, and healthy work environ-ments. Finally, health plans can act as good corporatecitizens, partnering with and advocating for effectivecommunity approaches, developing evidence-based rec-ommendations, and identifying research gaps.

In our profiles of selected health plans for this report, wefound that, as a group, plans are doing the above andmore. As the evidence for “what works" continues togrow, many health plans have implemented or are in theprocess of implementing innovative programs to addressoverweight and obesity. Plans are employing evidence-based strategies that emphasize long-term behavior modi-fication and strict criteria for weight loss surgical proce-dures to improve efficacy and patient safety. They aredeveloping and strengthening partnerships to help buildhealthier communities. Many plans are also evaluatingtheir obesity and weight management programs in aneffort to continue to expand the evidence base.

The plans featured in this report were chosen becausethey are implementing innovative, forward-thinkingstrategies in the fight against obesity and have emergedas partners in translating theory and concept into practi-cal options to address this epidemic. Significant workremains, however, if we are to get the obesity epidemicunder control. In the short term, there are specific measures— including the use of BMI as a vital sign— that can beimplemented across the health care system to better identifyand monitor obesity. In the longer term, the obesity epi-demic requires a new model of care and significant culturalchange to address its non-medical causes and management.Obesity is a complex problem that requires an equallycomplex solution. Experts agree that only through a broadpublic-health based approach that leverages public andprivate resources and expertise can we begin to makeprogress against this epidemic.

11

PLAN PROFILES


the pilot program, which includes materials that are cul-turally and ethnically appropriate.

Based on the results of the health risk assessment, membersdetermined to be eligible for the program are assigned toone of three groups:

n Low risk: BMI of 25 to 29.9 with no co-morbid conditions

n Intermediate risk: BMI of 30 to 34.9 with co-morbidconditions but no hospitalizations

n High risk: BMI of 35 or greater with co-morbid condi-tions and hospitalizations

All participants, regardless of risk group, receive an initialphone call from a nurse and a dietician to set up a weightloss program and coordinate the member’s participationin any other Aetna programs, such as disease manage-ment programs for diabetes or coronary artery disease.Participating members receive follow-up calls at regularintervals that vary based on risk level. The purpose of thefollow-up calls is to assess progress and medicationadherence, help the member stick to their weight loss pro-gram, and make any modifications needed. Members inthe high-risk group are also contacted by a weight losstherapist to assist them with behavior modificationrelated to their weight loss program.

At various points during the program, participatingmembers receive motivational tools and non-financialincentives to encourage them to continue their efforts.The incentives are strategically implemented at three, sixand nine months to encourage success and reduce attrition.Examples of incentives include pedometers and couponsfor community-based weight management programs. Theuse of financial incentives is under consideration.

Aetna sees several benefits to its weight management pro-gram, beyond helping members achieve and maintain ahealthy weight. Additional benefits include:

n Members who lose weight should be able to discontin-ue medications used to treat co-morbid conditions;

n Counseling patients on appropriate medications perdisease state should improve medication effectivenessand adherence to regimen;

n Decreased existence of co-morbid conditions;

Aetna

As a national insurer with a number of Fortune 500accounts, Aetna is eager to work collaboratively withemployers to address the growing problem of overweightand obesity. Aetna is a founding member of the NationalBusiness Group on Health’s Institute on the Costs and HealthEffects of Obesity (www.wgbh.com/healthy/about.cfm),which is examining employer focused solutions to obesityand overweight. On June 3, 2004, Aetna announced itwas launching a pilot weight management program,Healthy Body, Healthy WeightSM, that it hopes will informthe development of programs for broader rollout in 2005and beyond. The announcement was made at the 2004Time/ABC News Summit on Obesity.

Obesity and Weight Management Pilot Program

Aetna’s pilot program was designed to meet the needs ofthe morbidly obese, as well as those who are moderatelyoverweight, and everyone in between. The focus of theprogram is the development of healthy lifestyles; earlyintervention is seen as critical to change behaviors priorto the onset of costly co-morbid conditions.

All members are asked to complete a general health riskassessment via the web or on paper, which evaluates eli-gibility for a number of Aetna programs and also assessesthe member’s receptiveness to outreach activities, includingmailings and phone calls. Members who qualify for theweight management program must opt to participate andmay opt out at any time. Aetna has decided not to useclaims analysis to identify potentially eligible members atthis time due to inconsistencies in coding that make itdifficult to identify obese members who do not have oneor more co-morbid conditions. The pilot program is opento adults only at this stage. As with other health issues,ethnic disparities and cultural differences are importantconcerns that require tailored and flexible approaches,and Aetna has taken that into consideration in designing

Participating members receive follow-upcalls at regular intervals that vary basedon risk level. The purpose of the follow-upcalls is to assess progress and medicationadherence, help the members stick totheir weight loss programs, and makeany modifications needed.

n Decreased utilization of medical services; and

n Decreased rate of progression to bariatric surgery.

Coordination with Physicians

An important component of the Aetna pilot program isoutreach and coordination with network physicians. Aetnarecently sent primary care physicians (PCPs) in its net-work educational materials and tools (e.g., BMI charts)designed to help them reinforce messages in the clinicalsetting that their patients are receiving in the pilot. Inaddition, PCPs for all participating members are notifiedwhich of their patients are participating in the pilot pro-gram. For patients in the high-risk group, PCPs are alsocontacted directly by Aetna to review the patient’s med-ical history, medications and assessed status, as well asguidelines for treating co-morbid conditions and medicalfollow-up.

Bariatric Surgery and Weight Loss Medications

Bariatric surgery is typically not covered unless pur-chased as a separate rider or required by law. In stateswhere bariatric surgery is required, Aetna is working toestablish Centers of Excellence. Drugs used for the solepurpose of weight loss are generally not a covered benefitunder most Aetna policies unless purchased as a rider. Ifthey are covered, members must meet specific criteria todemonstrate medical necessity.

Pilot Feedback May Drive Further Program Refinement

At the conclusion of the pilot program, Aetna will evalu-ate the program’s impact by looking at “before and after"measurements of BMI, weight, and blood lipid and glu-cose levels. The results of the evaluation will informfuture changes and additions to the program as Aetnaprepares for a broader rollout next year.

Affinity Health Plan

Of all the statistics about the obesity epidemic in thiscountry, perhaps the most alarming are those concerningrates of overweight and obesity among children. A recentstudy by the New York City Department of Health andMental Hygiene, for example, found that almost 50 percentof New York City children were overweight or obese. Someexperts have speculated that unless we reverse currenttrends, this generation of children will be the first thatfails to outlive its parents. Statistics show that childhoodobesity is especially prevalent among the poor. As aresult, health plans that serve predominantly low-incomepopulations are especially feeling the impact of overweightand obesity.

Childhood Obesity Pilot

Affinity Health Plan—a Bronx-based health plan thatserves nearly 200,000 Medicaid and SCHIP members inthe five New York City boroughs and surrounding coun-ties— recognized that obesity was becoming a significantissue for its membership, especially among children. As acondition of participation in the Medicaid program, healthplans are required to implement ongoing PerformanceImprovement Projects (PIPs) for their members. Affinitybelieved that obesity was an ideal candidate for a PIP. Thestate Medicaid agency agreed, even granting Affinity anextension on its evaluation timeline for the programbecause it believes the findings are so important for theMedicaid program.

In late 2003, Affinity launched a pediatric weight man-agement pilot program aimed at obese members betweenthe ages of eight and eighteen. Members must be referredby their primary care physician (PCP) but can also requestthat their PCP evaluate them for the program. Final eligi-bility determinations are made by Affinity, based on thePCP’s examination. Program enrollment is typically limit-ed to children and adolescents who are considered obese.Once identified for the pilot, members must be evaluatedby a specialist— usually a pediatric endocrinologist — toidentify any important medical issues that would precludeparticipation or that need to be monitored by the mem-ber’s PCP during participation in the program. This is aunique and important feature of the Affinity pilot andone that highlights the clinical challenges of treating over-weight and obese children and adolescents.

PLAN PROFILES 13

of the steps required to start and maintain a programsite. It is hoped that these documents, which are cur-rently under development, in conjunction with theforthcoming evaluation report, will help simplify abroader roll-out of the program in the near future aswell as help other plans that are interested in implementing similar programs. It is also hoped thatother plans will implement similar programs using theexisting pilot sites so that the sites can maintain sufficient enrollment to continue operating. To furtherthis goal and to develop ideas for additional clinicaland community-based interventions, Affinity hosted a


Members who are not disqualified by a medical conditioncan enroll in an 8-12 week group program at one of fivepilot sites based primarily on geographic proximity andspace availability.

Content and Structure. The specific content of the pro-grams and the degree of medical versus behavioral orien-tation vary across sites but are typically centered on oneor more of the following categories:

n Goal settingn Environmental managementn Diet planningn Fitness activitiesn Cognitive training

Sessions are led by health professionals, including pri-mary care physicians, physical therapists, health educa-tors, nutritionists and psychologists. Most of the sitesincorporate parent involvement as an important aspect ofthe program.

Since the pilot began, 72 members have enrolled with amean BMI of 35. An evaluation of the program is expect-ed to be released in early 2005 and will help guide abroader rollout of the program. The evaluation will com-pare medical indicators between the baseline and exitassessments and will compare utilization and cost sixmonths prior to and after study participation. The effec-tiveness of the site-specific teaching models in encourag-ing and retaining parent involvement will also be a keypart of the evaluation.

Challenges and Future Efforts

While proud of their accomplishments thus far, Affinity isalso candid about the challenges it has faced in imple-menting its pilot programs. As anticipated, they havestruggled with attendance and attrition among the chil-dren and adolescents and their parents. Several sites thatwere originally part of the pilot were unable to maintainsufficient enrollment with Affinity members alone andhad to discontinue their programs. Affinity also encounteredseveral unexpected challenges, including the need to rapid-ly credential nutritionists for the program to participatein their provider network.

These challenges have sparked an effort to develop sever-al “lessons learned" papers and a complete documentation

To develop ideas for additional clinicaland community-based interventions,Affinity hosted a roundtable meeting inFebruary 2005 with local researchers,health plans and providers as well asrepresentatives from the pilot sites.

develop a set of “consensus guidelines" to serve as stan-dards for selecting the most appropriate patients, the mostexperienced surgeons and the best equipped facilities acrossthe state for weight loss surgery. In cases where there areserious co-morbidities involved, Affinity has approvedweight loss surgeries for adolescent members.

Weight loss drugs are covered, with prior approval, forAffinity’s non-Medicaid membership. Drugs are “carvedout" of New York’s Medicaid managed care programand provided through the traditional fee-for-serviceMedicaid program.

roundtable meeting in February 2005 with localresearchers, health plans and providers as well as representatives from the pilot sites.


Affinity covers bariatric surgery for adult members whomeet medical necessity criteria (based largely on the NIHguidelines). Affinity has also been a leader in the effort bya consortium of New York health plans and providers to

PLAN PROFILES 15

Medicare and Medicaid – MajorInsurers with Major Roles

With 52 million members and $300 billion inexpenditures in 2004, Medicaid is the nation’slargest health care program. Following closebehind, Medicare covered 40 million membersand had $290 billion in expenditures in 2004. Arecent study by Eric Finkelstein, Ph.D. and col-leagues estimated that total annual expendi-tures attributable to obesity in the United Stateswere approximately $75 billion in 2003, of whichmore than half were financed by Medicare($17.7 billion) or Medicaid ($21 billion). Aswith the private insurers profiled in this report,Medicare and Medicaid are struggling to findsolutions to the problems of overweight andobesity that are affecting the lives of millions oftheir members.

How Medicare and Medicaid ProgramPolicies Have Addressed Obesity

Medicare CoverageFederal Medicare law dictates that paymentsare not to be made by Medicare if expenses arenot “reasonable and necessary for the diagno-sis or treatment of illness...” In July 2004,Secretary of Health and Human Services TommyThompson announced a major Medicare policychange, which removed language that hadspecifically prohibited payment for obesitytreatments because obesity was not classifiedas an illness. Medicare has always paid fortreatments (with the exception of drug treat-ments) if obesity was caused by, aggravatedby, or otherwise directly related to another disease. Medicare did not pay for obesity

treatments if there were no other co-morbidconditions, however. This policy change is sig-nificant because it opens the door to a reviewby the Medicare Coverage Advisory Committeeof clinical trial data on the effectiveness of vari-ous obesity treatments. This policy change isalso significant because Medicare coveragedecisions often have far-reaching implicationsfor private insurance coverage and reimburse-ment policies, as well as medical research andteaching priorities.

Medicaid CoverageUnlike Medicare, which is a federally operatedand financed program, Medicaid is a joint feder-al-state program. Within broad federal guide-lines, states have flexibility in determining thetype, amount, duration and scope of services.Federal law also provides that a state mayexclude and restrict coverage of prescriptions ifthey are not for medically accepted indications.As a result, many states have long coveredanti-obesity pharmaceutical products despitethe fact that consensus has only recentlyemerged that obesity is an illness. While statestypically apply criteria similar to the Medicare“reasonable and necessary” language, eachstate has a different coverage policy withrespect to what is covered, for what purposes,and whether prior authorization is required.

Many states have implemented disease manage-ment programs to help coordinate care for theirbeneficiaries with chronic conditions such asasthma, diabetes, and congestive heart failure.As with the private health plans profiled in thisreport, state Medicaid programs will likely start tomore closely coordinate weight management

programs with existing disease managementprograms, and some will establish freestandingobesity disease management programs.

Implications for Medicare and MedicaidHealth Plans

Many Medicare and Medicaid beneficiariesreceive their benefits through managed careplans under the Medicare Advantage programand through health plans that contract withstate Medicaid agencies.

Medicare and Medicaid programs typicallypermit managed care organizations to use anysavings generated to provide additional services— beyond those required by law — as a meansof attracting members to their plan. ManyMedicare and Medicaid managed care plansalso offer care coordination activities that are notpart of the traditional program. It remains to beseen how Medicare and Medicaid health planswill respond to the growing problem of obesity,but plans are starting to look at what combina-tion of benefits and care coordination are mosteffective for their overweight and obese mem-bers. For example, the Affinity and WellPointprofiles in this report provide two good examplesof how health plans are addressing obesityamong their pediatric Medicaid members.

Sources:Finkelstein et al. “State-Level Estimates of Annual MedicalExpenditures Attributable to Obesity”, Obesity Research,January 2004. Other studies have estimated total annualobesity costs of up to $117 billion in 2000. See, Wolf AM,Colditz GA. “Current estimates of the economic cost ofobesity in the United States.” Obesity Research. 1998Mar;6(2):97-106.


teaching middle school students about nutrition andphysical activity, which was designed by researchers atHarvard University's Prevention Research Center onNutrition and Physical Activity.

Jump Up and Go! Clinical InitiativeThe clinical initiative includes three components:

n Clinicians’ ToolkitIn 2003, BCBSMA introduced a toolkit comprised ofeducational materials to assist pediatric clinicians inaddressing childhood obesity with their patients. BCBS-MA, in coordination with the Massachusetts Departmentof Public Health, made the Jump Up and Go! Clinicians’Toolkit available free-of-charge to all family and pedi-atric providers throughout Massachusetts. The toolkitincludes nutrition and physical activity fact sheets,physical activity and nutrition surveys, prescription forbetter health forms, body mass index(BMI) growth chartsfor patients aged 2-20, BMI calculation wheels, 5-2-1Jump Up and Go! weekly logs, and other educationaltools and charts to assist doctors in incorporating BMImeasurements into their regular check-up routines.

n WebMD CME courseBCBSMA, in partnership with WebMD/Medscape andthe Centers for Disease Control and Prevention, hasdeveloped online continuing medical education(CME)courses that physicians nationwide can enroll in free ofcharge (www.medscape.com/viewprogram/3221). Thecourses are designed to further educate physiciansabout the clinical tools and methods available for treat-ing obesity and communicating with at-risk patients.

n Outpatient Treatment ResearchRecognizing the unique role that community healthcenters and hospitals play in urban areas where manyyouth are at high-risk for obesity and obesity-relateddiseases, BCBSMA initiated a research study in 2004

Blue Cross Blue Shield of Massachusetts

Blue Cross and Blue Shield of Massachusetts (BCBSMA)has developed and implemented an array of products andcommunity-based initiatives that address the weightmanagement, nutrition and physical activity needs ofMassachusetts residents. Both members and non-members of the health plan benefit from BCBSMA’s support of evidence-based programs that prevent eatingdisorders and promote healthy nutrition and activity asopposed to dieting.

Community-Based Wellness Initiatives

In response to data indicating that children’s participationin physical activity was in significant decline and childhoodobesity was on the rise, BCBSMA initiated a youth wellnessprogram called Jump Up and Go! (www.jumpupandgo.com)in 1998. Jump Up and Go! was developed to help childrenand families throughout Massachusetts become more physi-cally active and adopt more nutritious eating habits. Today,Jump Up and Go! is comprised of four primary initiatives:

n A community initiative,n A school initiative,n A clinical initiative, andn A public awareness campaign.

Jump Up and Go! Community InitiativeThrough grantmaking, BCBSMA aims to increase thecapacity for community-based organizations, such asYMCAs, the Girl Scouts, and Boys’ and Girls’ Clubs, toprovide youth physical activity programs.

Jump Up and Go! School InitiativeThrough the awarding of grants each year, BCBSMAfunds the implementation of Healthy Choices, a school-based fitness and nutrition program, in public middleschools throughout Massachusetts.

Administered by the Massachusetts Department of PublicHealth, individual Healthy Choices grants total $9,000over the course of a three-year-period. The grant-recipi-ent schools are selected through a review process thatrequires the selected schools to implement the PlanetHealth curriculum, an interdisciplinary curriculum for

One-third of Massachusetts’ publicmiddle schools received HealthyChoices grants from BCBSMA forthe 2004-05 academic year.

calories burned, set monthly goals, document com-ments, and view progress reports.

n “Keep Moving" Program. BCBSMA provides financialsupport and guidance as a board member for thisstatewide senior walking program. Keep Moving(www.mass.gov/dph/tch/elderhealth) is a network ofcommunity-based walking groups that meet severaltimes a week.

n MA Senior Games. BCBSMA is a lead financial sponsorand board member of this annual statewide athletic com-petition, as well as the host of a health fair at the event.

Weight Management Benefits for BCBSMA Members

BCBSMA members have access to a range of programsand services to encourage and assist them in their effortsto make healthy lifestyle changes, including:

n A fitness benefit of $150 annually towards membershipdues or exercise class fees at any qualified health club;

n Discounts of up to 30 percent off standard retail ratesfor personal visits to network registered dieticians;

n A $150 annual benefit towards Weight Watchers® or ahospital-based weight management program, and freeregistration for all Weight Watchers® programs;

n A Medical Nutrition Therapy Benefit, which encour-ages members with medical conditions warrantingweight loss interventions to seek a referral from theirprimary care provider for covered visits to BCBSMA’snetwork of registered dieticians;

n Access to www.Ahealthyme.com, a website launchedin 1999, which features hundreds of articles, resources,and interactive tools on fitness and nutrition;

n MyBlueHealth, an online resource launched in February2004 to provide members with easy access to wellnesstools such as a personal health assessment, a fitnessbehavior change program module, a nutrition behavior

PLAN PROFILES 17

of best practices among existing community healthcenter and hospital programs that treat overweightyouth. The study’s findings will be used to develop atreatment protocol for health center and hospital-based overweight intervention programs.

Jump Up and Go! Public Awareness CampaignBCBSMA hosts a multitude of community events andsponsors television campaigns to continually support theprogram’s messages. In addition, BCBSMA has committedto establish a permanent Jump Up and Go! exhibit at theChildren’s Museum of Boston. BCBSMA is also currentlydeveloping toolkits for parents and teachers and is creat-ing a series of educator training sessions targeted specifi-cally to elementary school teachers.

Other Community-Based InterventionsBCBSMA has additional community-based programs inplace for adults throughout Massachusetts:

n GoWalking! 5K Walk and Health Fair. This annualfamily-oriented community 5K walk and health fairprovides the Boston community with an opportunity tolearn more about the healthy benefits that come fromstarting and maintaining a regular walking program.

n GoWalking! Web-Based Program. This web-basedprogram, recently created by BCBSMA, contains edu-cational information, a list of walking resources andmapped-out walking routes in Massachusetts, and itprovides details on upcoming walking events. Throughthis website, participants have the ability to customizea walking program, receive motivational e-mails, anduse interactive tools to track distance walked, calculate

In 2005, BCBSMA will awardgrants for the development and implementation of healthcenter-based treatment programsthat incorporate the best practices protocol identified in the 2004 study.


Blue Cross and Blue Shield of North Carolina

Blue Cross and Blue Shield of North Carolina(BCBSNC) isaddressing weight management issues for plan members,as well as for residents of North Carolina, through a newnationally recognized weight management program andthrough the activities of its Community Relations depart-ment. BCBSNC continues to provide and promote tools toencourage healthy lifestyles for BCBSNC members, inaddition to at-risk populations throughout North Carolina.

BCBSNC recently analyzed member data and data fromthe U.S. Department of Health and Human Services thatindicated nearly 60 percent of all North Carolina residentsand 55 percent of adult BCBSNC plan members are eitheroverweight or obese. BCBSNC conducted additional analy-ses of the BCBSNC membership using claims data, whichrevealed that overall medical and pharmacy claims forobese members were costing 32 percent more than mem-bers within normal weight guidelines, and overweightmembers cost 18 percent more. Overweight and obese

change program module, and “trackers" for monitor-ing biometrics;

n A new telephonic walking advisory program for memberswho are enrolled within specific provider groups; and

n Worksite wellness implementation kits for physicalactivity and weight management, which are providedto all BCBSMA accounts. In addition, BCBSMA hasbeen offering one-hour educational seminars foremployee populations to all accounts since 1997.


Gastric stapling, bypass and banding are covered at BCB-SMA-approved facilities for adult members who meet thefollowing criteria:

n A BMI greater than 40, or greater than 35 with one ormore co-morbid conditions;

n Failed attempts at weight loss in the past;

n At least five years of obesity; and

n Obesity is not due to an untreated metabolic cause.

The weight loss drug Orlistat (Xenical) is available tomembers with BMI greater than 30, or a BMI greater than 27 if also diagnosed with hypertension, diabetes or hyperlipidemia.

BCBSNC found that ER visits for obesemembers were 240 percent higherthan for members of a normal weight.Outpatient utilization for obese memberswas 40 percent higher and they had25 percent more office visits.

PLAN PROFILES 19

BCBSNC Weight Management Initiatives for Members

The Healthy Lifestyle ChoicesSM program (www.bcbsnc.com/members/hmp/healthylifestyle.cfm) is the most recentBCBSNC initiative to address obesity within the BCBSNCplan. The program, launched in August 2004, has a memberand provider component.

Member ComponentMember participation in the Healthy Lifestyle ChoicesSM

program is voluntary. Currently, BCBSNC promotes thisprogram to members who are identified through claimsdata as having conditions that are related to being over-weight (i.e., hypertension, metabolic disorders, etc.).General plan promotion of the program is planned tooccur in the future, at which time physician and memberself-referrals into the program will be made available toall plan members.

members were found to account for $83 million in excessmedical and pharmacy claims costs to BCBSNC in 2003.13

In response to these findings, BCBSNC launched severalinitiatives to encourage healthier lifestyles, while simul-taneously reducing excess medical and pharmaceuticalcosts exacerbated by unhealthy lifestyles. These initia-tives include:

n A new weight management program available to planmembers, which includes coverage for up to fourphysician office visits per year for the evaluation andtreatment of obesity;

n Additional value-added weight management initia-tives for plan members; and

n Community-based initiatives that target all residentsof North Carolina.


bariatric surgeries performed in addition to quality,based on analysis of data and associated outcomes. Asof August 2004, identified Centers of Excellence arelisted in the BCBSNC provider directory.

Program OutcomesThe primary goals of the Healthy Lifestyle ChoicesSM pro-gram are to reduce the incidence of diabetes, cardiacdisease and obesity prevalence; to enhance the manage-ment of members with lifestyle-related illness; to providesafe and effective treatment models; to increase providerassessment and counseling; and to encourage nationalleadership and innovation. BCBSNC will evaluate thesuccess of the Healthy Lifestyle ChoicesSM programthrough ongoing measurement of key outcome andprocess measures, including the following:

n Utilization and costsn Incidence of Type II diabetes onsetn Pounds lostn Waist circumference inches lostn Member satisfaction with programn Provider assessment of BMI and counselingn Utilization of program componentsn “Blue ExtrasSM" program utilization

Other Weight Management Initiatives for MembersBCBSNC members diagnosed with diabetes, congestiveheart failure, or coronary artery disease are enrolled indisease management programs that are specific to thoseconditions. These programs include lifestyle and weightmanagement components as appropriate and as related tothe underlying diagnosis. At this time, the initiatives with-in the disease management programs are not directlycoordinated with the Healthy Lifestyle ChoicesSM program.However, as the new Healthy Lifestyle ChoicesSM programevolves over time, BCBSNC will determine an appropriateway to incorporate components of the program into thespecific disease management programs, to ensure thatmembers enrolled in disease management programs haveaccess to all components of an inclusive weight manage-ment program as needed.

In addition to the new Healthy Lifestyle ChoicesSM programand disease management programs, BCBSNC membershave access to an array of value-added programs collec-tively referred to as Blue ExtrasSM. Blue PointsSM is one

Once enrolled into the program, members are risk-stratifiedbased on clinical factors in addition to readiness to change.Standard program components, offered to members in allrisk levels, include educational self-help materials andaccess to a unique web-based interactive program thatoffers customized feedback to members. Supplementarynutrition counseling and access to FDA approved weightloss medications will also be made available to membersafter October 1, 2005, as determined appropriate basedon individual risk levels. Bariatric surgery options arecurrently available through BCBSNC with appropriateprior-authorization.

Provider ComponentThe provider component of the Healthy Lifestyle ChoicesSM

program includes an obesity prevention “toolbox". This“toolbox" is one mechanism used to encourage providers tointegrate the body mass index(BMI) and waist circumfer-ence as a vital sign. The “toolbox" contains guidelines onobesity assessment and treatment options, chart stickersto assist the provider in tracking progress, waist circum-ference measurement tools and patient education tearsheets. The “toolbox" available at this time is for adultmembers; however, a pediatric “toolbox" will also beavailable in early 2005. Participation in the Healthy LifestyleChoicesSM program is strictly voluntary for providers, andas of April 1, 2005, will allow for coverage of four officevisits for assessment and treatment of obesity per benefitperiod. Providers who may participate include both primarycare providers and specialty care providers.

An additional and important component of the HealthyLifestyle ChoicesSM program is the development andidentification of Centers of Excellence for obesity surgi-cal procedures. Although members who receive prior-authorization for bariatric surgery may choose anyprovider to perform the procedure, those facilities thatare established as Centers of Excellence are stronglyencouraged. The Centers of Excellence are objectivelyestablished by BCBSNC based on the volume of

All physicians in the BCBSNC physician advisory committeehave expressed an interest in theprovider component and haveassisted in the development ofthe “toolbox”.

PLAN PROFILES 21

n A business outreach component that promotes work-site wellness “best practices";

n Fit Together initiatives in designated communities tohighlight local community efforts to promote physicalactivity and healthy eating through assessment, collab-oration and resources; and

n Grants to community-based obesity prevention initiatives.

The BCBSNC Foundation, whose mission is to providefinancial support to improve the health and well-being ofNorth Carolinians, was started in November 2000. TheFoundation funds programs that increase access to healthcare and promote preventive care. One of the foundation’sfour focus areas is physical activity. Programs funded bythe BCBSNC Foundation include:

n Be Active Kids: An interactive nutrition and physicalactivity initiative for children ages four and five. BCBSNC provided the initial resources to develop thisprogram in 1997 and continued funding until theFoundation began funding the program in 2001. BeActive Kids (www.beactivekids.org) is in all 100 NorthCarolina counties, has won over 16 national awards andis administered by Be Active North Carolina.

n Active Blue Van: A brightly colored van that attendscommunity events across the state to promote physicalactivity. Those who visit the van may receive literatureabout physical activity and nutrition, participate infun activities including hula-hooping and jump roping,and, beginning in January 2005, complete a physicalactivity assessment.

such program that encourages BCBSNC members to bephysically active. Based on the honor system, membersrecord their physical activity levels and are awardedprizes for being physically active.

Community-Based Programs/Initiatives

BCBSNC is actively involved in many community-basedinitiatives that are available to all residents of NorthCarolina. BCBSNC offers grants and resources for healthrelated initiatives to communities and organizationsthrough both corporate contributions and the BCBSNCFoundation.

BCBSNC has recently partnered with the Food Bank ofEastern and Central North Carolina to expand the KidsCafé Program to all 34 eastern counties of NorthCarolina over a five-year period. This after school pro-gram helps children at risk of hunger by providingnutritious meals, nutrition education, tutoring and men-toring, and physical activity.

BCBSNC is also the founding sponsor of Be Active NorthCarolina, Inc. (BANC), a non-profit organization whosemission is “to increase physical activity and encouragehealthy lifestyles among North Carolinians through peo-ple, programs and policies.” (www.beactivenc.org) BANCadministers physical activity programs targeting differentage groups through grants and sponsorships from BCB-SNC, the BCBSNC Foundation and many other funders.

Most recently, BCBSNC has developed a partnershipwith the North Carolina Health and Wellness Trust FundCommission to create and develop Fit Together(www.FitTogetherNC.org). This 3-year prevention initia-tive, which began April 2004, incorporates:

n Motivational ad campaigns;

n A web-site that promotes initiatives available withinindividual communities;

The Blue PointsSM program is highly utilized by members, with over45,000 members taking advantage of it to date. Although the programhas not been formally evaluated, feedback has been very positive.


n A 24 x 7 NurseLine to assist members in accessingappropriate services to address their needs.

However, despite this array of programs, enhanced bene-fits, and educational components, Empire found that alarge portion of its membership was not being reachedbecause of various barriers impeding accessibility. Empiredetermined that programs offered would need to be con-venient for members to join and maintain participationand be personalized to achieve impact. This determinationwas the driving impetus that led Empire to develop a newand innovative grassroots education program for its cus-tomer accounts.

Worksite Intervention Program

The challenge in developing this new program was tomaintain participation, achieve long-term changes indaily activity levels, and have participants consistentlymake correct food choices. With these goals in mind,Empire developed a new worksite wellness program, TheHealthy Weigh to Change. This program was piloted atone large employer worksite and is being expanded totheir other locations beginning in 2005.

The program strategy is to achieve success by encouragingincremental lifestyle changes leading to permanent healthyhabits. The Healthy Weigh to Change meets one hour aweek for eight weeks and is taught by RDs certified inadult weight management training. Although each partici-pant’s weight and BMI are checked during the first and lastclass, the program is open to all individuals regardless ofBMI. The focus of each session is to teach participants howto maintain a healthy lifestyle through behavior changes,as opposed to just losing weight quickly. Each sessionincludes a lecture, small group discussions, and questionand answer session. The RD reviews the participants’ week-ly homework assignments and provides incentives thathave been aligned to support the class topic, such as waterbottles and insulated lunch bags.

Each participant receives a binder with all session contentand homework assignments, as well as activity logs, fooddiaries, a pedometer and sample food menus to assist withmeal planning. Empire integrated Blue Cross Blue Shield’sWalking WorksSM into The Healthy Weigh to Change,

Empire Blue Cross Blue Shield

Empire Blue Cross Blue Shield has established models ofawareness and behavior modification through a depart-ment fully dedicated to this effort. Established in 1995,the Health Education Department distinguishes Empirefrom other health plans in that this department is staffedwith clinical personnel, registered nurses(RNs) and regis-tered dietitians (RDs), whose focus is member healtheducation. The department provides education for thedevelopment and maintenance of healthful lifestyles with nutrition and weight management, smoking cessa-tion and stress management being the most integral.Interventions originating from the Health EducationDepartment are numerous and include:

n Preventive health reminders by mail and telephonen Member newslettersn Worksite wellness programsn Topic-specific worksite health events

Empire, aware of the many health and quality-of-lifeconsequences of being overweight or obese, establishednumerous educational tools to address weight manage-ment across its membership. The tools are part ofEmpire’s 360º Health program, which was established tointegrate resources available to members. The toolsinclude:

n A robust web site, established for membership, witheducational content on nutrition, physical activity andhealthy living, developed and maintained by the HealthEducation Department;

n An online four-week weight loss program, featuringlive chat sessions with a physician instructor;

n Access to pre-recorded education modules via telephoneon such topics as nutrition and physical activity;

n Worksite wellness programs (“lunch and learn" typesessions as well as on-site multi-week sessions);

n Educational mailings to adults and parents;

n A partnership with WebMD, which allows Empiremembers to access WebMD via the Empire web siteand utilize some of their special promotional eventson healthy living; and

PLAN PROFILES 23

Obesity-Related Prescription Drug Treatments

While much is known about the positive benefits of diet, exer-cise and lifestyle changes, less is known about the effective-ness, safety and appropriateness of obesity-related prescrip-tion drug treatments.

Background, Efficacy and Risks

Traditionally, medication for the treatment of obesity was pro-posed as a short-term “solution” for patients, who would pre-sumably adopt the lifestyle changes necessary to continue tolose weight and reach and maintain an “ideal body weight.” Inthe 1990s, the public health community began to view obesityas a chronic disease and the long-term use of medications aspotential treatment strategies. However, in addition to recurringquestions about their effectiveness, safety concerns about anti-obesity drugs surfaced. Today, it is well known that Redux, “FenPhen”, and over the counter drugs containing Ephedra, haveserious side effects. Nevertheless, despite these effectivenessand safety concerns, the class of anti-obesity drugs has expe-rienced strong growth in international sales.

Over the course of the forecast period in Figure 4, it is estimatedthat the total retail and hospital market for obesity will rise bymore than $1 billion to reach $1.6 billion in 2011, according to aleading market forecaster. This projection is primarily driven bythe reimbursement and wider availability of anti-obesity prepara-tions, as there is a growing body of thought that treatment leadsto a reduction in co-morbidities.

At present, drugs used for the treatment of obesity tend to fallinto three categories: stimulants, appetite suppressants andfat-absorption blockers. It is commonly known that many drugswith approved indications for other purposes, such as depres-sion, are prescribed and used “off-label” for obesity treatment.

The role of pharmaceuticals and obesity is becoming clearer asresearch focuses on the appropriate balance of pharmaceuti-cals and other treatment options. In focusing on effectiveness,the Agency for Healthcare Research and Quality in a recentEvidence Report stated that the weight loss associated with themost studied drugs has been modest ( less than 5 kg at 1 year)and that while this amount may be clinically significant, surgicaltreatment is more effective than non-surgical treatment forweight loss and the control of some co-morbidities in morbidlyobese patients. Therapies that involve more than one treatmentoption, or combination therapies, are generally considered tobe the most likely way to achieve efficacy of greater than 10 percent weight loss.

Health Plan Coverage

Health plans vary in their coverage policies of prescriptiondrugs. Coverage policies range from not covering weight lossdrugs at any level, covering under prior authorization, coveringwith a related condition, or requiring enrollment in a compre-hensive weight-management program prior to coverage. Thiswide-range of policies reflects the current state of knowledge asreflected in this sidebar discussion.

Sources: “Pharmacological and Surgical Treatment of Obesity” AHRQ No. 103, July 2004.“Obesity – The Science Behind Pharmacological Intervention.” Dr. Brian Huber,April 28, 2004 presentation at North Carolina Biotechnology Center. Summaryavailable at www.ncabr.org.“Pharmacological and Surgical Treatment of Obesity” AHRQ No. 103, July 2004.

Figure 4. *Global Sales of Anti-obesity Drugs (1992-2011)

*Global = The combined markets of Canada, France, Germany, Italy, Spain, UK, and USA.Source: “The ballooning obesity market: tough to burst.” IMS Therapy Forecaster, November 2004.

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ditions such as diabetes or coronary artery disease, andweight management is addressed within these programs asappropriate. CM enrollees are eligible to participate inother educational weight management programs offeredby Empire; however, the educational programs are notcoordinated with the enrollee’s CM program at this time.

Future Initiatives

As Empire continues to delve into the future of obesity andweight management, additional programs and integrationof existing programs will be explored and implemented asappropriate. A childhood obesity program is currently indevelopment as the next step. Empire is also actively con-sidering the addition of a telephone-based counseling com-ponent to make access to weight management even easier.

which encourages participants to form walking groups forregular exercise.

Early in the pilot program, Empire realized that almost 30percent of participants spoke only Spanish. Identifying thissignificant participation barrier, Empire added a bilingualinstructor to assist the two English-speaking teachers andprepared a Spanish version of all didactic materials as wellas supportive logs, diaries and brochures. As a result,100% of the Spanish-speaking participants who started theprogram completed the program, and the Spanish-speak-ing participants in the class became the leaders of an on-site daily walking group.

Measurement and evaluation are a key part of the pilot.The success of the program will be determined by:

n Participation Raten Weight Lossn Health Habits Behavioral Survey (conducted both pre-

and post-intervention)

Clinical Interventions

Empire BCBS has additional benefits available to mem-bers who are considered morbidly obese. Empire allowsfour physician office visits annually for treatment ofmorbid obesity. Physicians are required to measure andtrack the member’s BMI if prescribing any weight lossprescriptions or if bariatric surgery is planned. Individuals classified as morbidly obese who also haveassociated co-morbid conditions may be eligible forbariatric surgery and/or pharmaceutical interventions.Candidates for bariatric surgery must have a thoroughmedical and psychiatric evaluation indicating they arephysically and mentally prepared for the surgery andmust participate in ongoing group support sessions beforeEmpire will consider approving payment for the surgery.

Empire currently has condition management (CM) pro-grams available to members who are diagnosed with con-

100% of the Spanish-speaking participantswho started the program completed theprogram, and the Spanish-speakingparticipants in the class became the leaders of an on-site daily walking group.

PLAN PROFILES 25

n A pedometer;

n Daily motivational support; and

n Tools and resources, including online tracking logs tomeasure progress, nutritious recipes and customer service.

The new Lose Weight component of the 10,000 Steps®

Program, added in February 2004, incorporates additionaltools for self-management, including an innovative eatingplan that assists participants with increasing physicalactivity to boost metabolism and decreasing calories whilestaying full. Data indicate that participants who followthe weight loss strategies lose an average of seven poundsover an eight-week period.

The 10,000 Steps® Program is available to members ofHealthPartners for a $20 fee, in addition to nonmembersfor a slightly higher fee of $30. Non-member populationsinclude individuals from the general population whoare interested in participating, individuals who aremembers of other health plans that purchase this pro-gram from HealthPartners, or employees of an employ-er group that purchases the program. Kaiser Permanentehas recently partnered with HealthPartners to obtain the

HealthPartners

HealthPartners is well known for its research in the areas ofthe economic impact of obesity and the effective implemen-tation of weight management programs to address obesity.Through the HealthPartners Center for Health Promotion andthe HealthPartners Research Foundation, numerous studieshave been conducted that strongly support the value ofimplementing weight management programs. In responseto this research, HealthPartners has actively pursuedstrategic investments in weight management programsand interventions to promote healthy lifestyles amongplan members and non-members alike.

The 10,000 Steps® Program

The 10,000 Steps® Program (www.10k-steps.com), a 2004winner of the Innovation in Prevention Award from theDepartment of Health and Human Services and the NationalInstitute of Health Foundation, was initially launched in1999 by HealthPartners. The program has evolved as both abroad prevention program to increase physical activity as away to improve overall health, and as an intervention topromote weight loss for targeted individuals. The 10,000Steps® Program includes the following program components:

HealthPartners’ data indicate thatparticipants in the 10,000 Steps®

Program who followed the weightloss strategies alone lost an averageof seven pounds over an eight-weekperiod; taking 10,000 steps a day iscorrelated with approximately a fivepercent weight loss.


Program ComponentsA Call to Change…Healthy Lifestyles, Healthy Weight® uti-lizes an evidence-based written curriculum. Participantsreceive up to ten sessions of personalized counseling witha registered dietitian and exercise specialist and up to sixsupplemental sessions with content related to co-morbidconditions and/or body image issues associated withobesity. In addition, the 10,000 Steps® Program is fullyincorporated into the curriculum of the phone course.After completion of the telephone-based program, partici-pants are provided with a post-course session that occurssix months after completion of the curriculum.

Outcome data (clinical, behavioral, functional, and satisfaction variables) are collected at the initiation andcompletion of course and at other defined times.

Other Weight Management Programs Available to Members

In addition to the programs described above, additionalweight management interventions and initiatives areavailable to HealthPartners members.

Medical InterventionsBariatric surgery is a covered benefit for HealthPartnersmembers; however, there are defined criteria. Currently,the member must be evaluated and treated by a designat-ed weight loss surgeon who documents that the memberhas actively participated in non-surgical methods ofweight reduction for a significant period of time.HealthPartners is currently in the process of exploringthe possibility of incorporating additional specific require-ments to integrate HealthPartners weight managementprograms as a component of both the pre-surgery andpost-surgery process for bariatric surgery.

HealthPartners also covers some prescription weight lossdrugs for members. However, prior approval must begranted, and the member must meet certain criteria.Furthermore, enrollment and participation in the Call to

10,000 Steps® Program for its members and employees,available at www.kaiserpermanente.org/10000steps, effectiveOctober 1, 2004.

A Call to Change… Healthy Lifestyles, Healthy Weight®

A Call to Change…Healthy Lifestyles, Healthy Weight® is a telephone-based weight management program available,for a nominal fee, to adult members of HealthPartnerswho are enrolled in another HealthPartners disease man-agement program. Individuals may self-refer into theprogram, be referred by a provider or a disease manage-ment program in which the member is enrolled, or via ahealth risk appraisal completed at their worksite.

Screening processAll potential enrollees in this telephone-based programparticipate in an initial enrollment call to ensure that thephone program is an appropriate intervention for them.This initial call includes an extensive triage assessmentto evaluate the presence of any eating disorders or med-ical management issues, and to indicate if the potentialparticipant is ready to change. Research conducted byHealthPartners found that individuals who are willing tocommunicate about health improvement options are morelikely to be “ready to change". Individuals are only enrolledin the program after a determination is made that thereare no associated eating disorders or medical conditionsthat would affect participation, and that the individual iscommitted to changing.

Coordination with primary care physiciansAll notes from the initial call and subsequent calls aretracked and provided to the participant’s primary carephysician (with approval from the participant). Therefore,changes in members’ health status receive prompt attentionby physicians, which allows them to positively reinforcebehavior changes that are key to preventing chronic dis-eases and promoting risk reduction.

As of May 2004, approximately67,100 individuals were participatingin the 10,000 Steps® Program.

Early results show that participantsin the weight management Call toChange course lost an average of13 pounds (2BMI units) betweenbaseline and six-month post-coursefollow-up.

PLAN PROFILES 27

n Adolescent obesity. The HealthPartners ResearchFoundation, in collaboration with the University ofMinnesota, has embarked on a study to better understandadolescent and parent perceptions regarding weight,health promotion and types of weight managementprograms that would work for adolescents. This studywill ultimately provide the data for a large-scale clinicaltrial to help adolescents manage weight problems.

n Weight loss maintenance for adults. A currentresearch project addressing weight loss maintenancewill be used to propose a full-scale randomized trialevaluating the efficacy of weight maintenance inter-ventions over a two-year period.

n Keep Active Minnesota (KAM) Project. Funded by theNational Institute on Aging, this study will test newways to help older adults (ages 50-70) to maintainactive lifestyles.

Another recent initiative, being conducted in collaborationwith the Centers for Disease Control, Kaiser Permanenteand HealthPartners, is the translation of community guiderecommendations into clinical actions and solutions. Thegoals of this initiative are to identify actionable solutionsto address overweight and obesity in medical care settingsbased on scientific evidence and professional experience;to assess solutions in the context of clinical effectiveness,administrative reality, and financial feasibility; and tomake final recommendations which enumerate specificsolutions to be targeted for expanded implementation and dissemination.

To coordinate and formalize organizational goals, strategiesand measures related to the full care spectrum for over-weight and obese individuals, HealthPartners has createdthe HealthPartners Enterprise Obesity Steering Committee.This multidisciplinary team is charged with exploring anumber of specific interventions, including new approachesto incorporate and encourage the use of physician tools topromote the use of BMI as a vital sign and to incorporatepharmacotherapy as appropriate.

Change…Healthy Lifestyles, Healthy Weight® program isrequired of all members who receive these drugs.HealthPartners has a variety of disease management pro-grams available for members with specific chronic diseases,including diabetes, congestive heart failure, coronaryartery disease, asthma and chronic obstructive pulmonarydisorder. These disease management programs are fullycoordinated and integrated with the Call to Change…HealthyLifestyles, Healthy Weight® program, as appropriate.

Other Weight Management InterventionsIncentives for HealthPartners members to stay fit are pro-vided through the HealthPartners Frequent FitnessProgram, which includes discounts at numerous fitnessfacilities and exercise equipment retailers. If a memberworks out at least eight times a month at a participatinghealth club, they are rewarded for improving their healthwith monthly savings off their club membership fees.

In addition, HealthPartners offers the Worksite Health-e-KitSM web-site, consisting of four programs (physicalactivity, healthy eating, stress management, and self-care)which last three months each. This web-based program isavailable to employers and provides tools for employersto roll out programs to reach employees at all levels ofhealth risk and readiness to change. The program inte-grates scientifically proven approaches to promote behav-ior change.

Other Initiatives

HealthPartners is actively exploring new weight man-agement initiatives that may hold promise as futureinterventions. The HealthPartners Research Foundationis a strategic partner in the Minnesota Obesity Center,an Obesity Nutrition Research Center funded by theNational Institute of Diabetes, and Digestive and KidneyDiseases of the National Institutes of Health. In addi-tion, HealthPartners, in collaboration with the Institutefor Clinical Systems Improvement (ICSI) and othersponsors, has been involved in the writing of the newICSI guidelines on prevention and management of obe-sity, released in November 2004. The ICSI is sponsoredby six Minnesota health plans.

HealthPartners Research Foundation is actively involvedin several grants related to the study of obesity:

Increased physical activity amongolder adults is associated with lowerhealth care charges within twoyears, relative to those who werepersistently inactive.


Highmark, Inc.

Highmark recognized the impact and prevalence of child-hood obesity and responded by initiating a comprehen-sive approach to address childhood obesity in late 2001.Since that time, Highmark has brought together numer-ous community partners to address this issue, includingthe Pennsylvania chapter of the American Academy ofPediatrics, the Western Pennsylvania Hospital Council,local and state health departments, the PittsburghFoundation and Pittsburgh Public Schools.

Working in committees, the group has identified andimplemented strategies to address the epidemic regionally.Additionally, Highmark has funded several significantregional initiatives, including a policy forum and a mediacampaign around childhood obesity. The HighmarkChallenge for Healthier Schools has provided $400,000 in grants to schools within its service region to introducenutrition and physical activity programs and a $500,000three-year grant to the Pittsburgh Board of Education tofund a system-wide physical education and nutritioncurriculum in grades K-8 affecting 28,000 children. InCentral Pennsylvania, over 32,000 elementary studentshave received daily planners that include health messagesand tips. A partnership with the Susan P. Byrnes HealthEducation Center in York has enhanced the initiative byaffording field trips to reinforce student health education.To provide support to physicians, Highmark developed atool kit that includes obesity identification and treatmentguidelines, parent self-help materials on nutrition andactivity, a BMI calculator and other materials.

KidShape® Evaluation

To complement broad, population-based prevention initiatives, Highmark offers the KidShape® program(www.kidshape.com), a nationally recognized pediatricweight management program targeted at overweightchildren and teens (aged 6 to 14) and their parents.Highmark’s introduction of the program in its serviceregion was in part a response to physicians who expresseda need for clinical interventions for their overweight andobese patients. The KidShape® program was first launchedin California in the late 1980s by a pediatric endocri-nologist, and it is now available at 18 sites in SouthernCalifornia and is also licensed to providers in San Antonio,Texas and Los Cruces, New Mexico. The KidShapeFoundation reports that, to date, 87 percent of the 1,500

One out of every four children oradolescents is overweight andtherefore at greater risk for anumber of chronic and debilitatingdiseases including high bloodpressure, worsened asthma, andeven heart disease.

PLAN PROFILES 29

and weight, at the first class with follow-up measurestaken eight weeks later at the last class. Participants willalso complete the Rosenberg Self-Esteem Scale and a self-administered survey of consumption of different foodgroups and frequency of physical activity during the firstand last sessions. Highmark will also assess programeffectiveness through monitoring enrollment levels andattendance, drop out and participation rates.

Longer-term follow-up data will be collected in coordina-tion with the enrollee’s family physicians when possible.Cost savings will be projected based on average decreasein BMI and published data indicating likely future medicalcosts for children with high BMI. To allow for this com-prehensive evaluation, participating families are asked tosign an informed consent form explaining the researchproject and how confidential data is handled and securean authorization from their physician for the release ofheight and weight information. However, participants arenot denied program entry if they do not wish to partici-pate in the research component, and they have the optionto rescind their agreement to participate in the researchproject at any time.

The formal launch of the KidShape® program has been asignificant commitment for Highmark. Although therehave been challenges in educating physicians about theprogram’s efficacy and in training service delivery teamsat several new sites simultaneously, Highmark believes ithas now rounded the learning curve. An initial 50 percentdropout rate was addressed by Highmark through improvedintake procedures to afford parents a better understandingof the commitment level necessary to be successful in theprogram, thereby enrolling those with the highest readinesslevels. Low graduation rates also appeared to be affectedby holiday absences. Sites are addressing this by holdingcohorts based on a typical school year schedule, with breaksfor winter holidays and summer. Current graduation rates(based on enrollees who attend at least six of the eightsessions) are approximately 80 percent.

participating kids lost weight during the program, and 80percent kept the weight off for up to two years.

Highmark has licensed the KidShape® program for use inPennsylvania and is financing this program in sites cho-sen to emphasize access for and referral of primarilyminority and underserved families. The program was ini-tially launched in two pilot sites in the fall of 2002. As ofOctober 2004, Highmark supports nine sites and expectsto launch the program in five to ten additional sites bymid-2005. Sites include, on average, two to three cohortsannually with 15-20 families in each cohort. By the endof 2005, Highmark hopes to have served close to 1,000families through KidShape®. Highmark covers costs for anyqualified individual to participate, regardless of whether theyare a Highmark member. However, a doctor referral indi-cating that the enrollee’s BMI is higher than the 85th per-centile is required for enrollment.

The KidShape® program, which is offered in English andSpanish, encompasses eight two-hour classes conductedonce a week at community-based sites. At least one par-ent is required to attend with an enrolled child. A struc-tured interactive curriculum is presented with standard-ized materials. Registered dieticians and mental healthand fitness professionals serve as instructors and mustundergo a two-day training. Follow-up contact andphysician involvement represent integral componentsof the program.

Highmark is piloting the KidShape® program to determineif it would be cost-effective to reimburse providers todeliver programs such as KidShape® in the future.Highmark researchers will collect data, including height

Preliminary data (Jan.–Aug. 2004) fromthe Kidshape Program indicate that aver-age BMI dropped from 29.02 to 28.48among 114 participating children acrossfive sites.

Highmark’s evaluation of the programin Pennsylvania will be the first timethe program is evaluated by anoutside entity, other than theKidShape Foundation.

The KidShape Foundation reports a favorable impact from program participation on serum insulin, blood pressure and triglyceridelevels among program participants.


programs to address wellness issues among employees.Highmark offers the following services through worksitewellness programs:

n Analysis of the employer’s population, based on datagathered from claims utilization, clinical screenings andhealth risk appraisals. This enables participants to berisk-stratified to assess the need for various interventions;

n Assistance in selecting the most effective lifestylechange programs available from Highmark and/orlocal and national resources and in defining measur-able program goals to monitor progress; and

n Assistance in a communication campaign, programimplementation and program evaluation.

Blues On Call (health coaching via phone) is an integratedcondition management program that provides memberswith information and support and helps callers develop theskills needed for ongoing chronic condition management.The program focuses on diabetes, congestive heart failure,coronary artery disease, asthma, chronic obstructive pul-monary disease and associated co-morbid conditions.Members may call 24 hours a day, seven days a week forcoaching on any medical topic. Blues On Call healthcoaches include registered nurses, respiratory therapists,certified diabetic educators and dieticians.

With the participant’s permission, Highmark forwardsall reports to each participant’s primary care physician,and the summary data are shared with health coachesfrom Blues on Call to further risk-stratify members forcondition management programs.

Bariatric Surgery and Weight Loss MedicationsHighmark offers clinical interventions to members whomeet defined criteria. Bariatric surgery is available tomembers; however, it is only provided to those who meetweight criteria and who have sought intervention throughan approved weight management program for at least sixmonths prior to the procedure. Prescription weight lossdrugs are currently covered for an underlying conditionthat is related to obesity; however, coverage exclusivelyfor weight loss is not available to members at this time.

Weight Management Initiatives for Members

Highmark offers online programs, programs through partnerorganizations, worksite wellness programs and clinicalinterventions to assist members in addressing weightmanagement issues.

Online Weight Management ProgramsAs of January 2004, Highmark began offering onlinehealth programs free of charge to all adult members. Twoprograms, which specifically address weight management,include:

n HealthMedia Balance®, which provides participantswith weight management tips and self-monitoringactivities through personalized electronic messages.The program also focuses on physical activity andbody image to address all of the components that leadto excess weight.

n HealthMedia Nourish®, another self-management pro-gram that focuses on nutrition and provides an initialaction plan with three follow-up plans delivered attwo, four and eight weeks. It includes personalizedtechniques for making appropriate food choices whendining out, shopping and preparing meals.

Partnership ProgramsThrough its Preventive Health Services Division, Highmarkworks with partner organizations including local YMCAsand community hospitals to provide member services thataddress weight issues, including:

n Personal nutrition coaching for children and adoles-cents who are overweight (>95 percentile BMI for ageand sex) or at risk for overweight (BMI between 85and 95 percentile for age and sex), and

n Eat Well for Life, a program that helps participantsdevelop skills for eating appropriately and makinghealthy food choices.

Worksite WellnessThrough the Preventive Health Services Division,Highmark offers a data-driven worksite wellness programin which Highmark worksite wellness professionals con-sult with employer groups to develop strategies or design

PLAN PROFILES 31

n Youth Mentoring Program. Horizon has an ongoingpartnership with the New Jersey Boys and Girls Clubsto provide teen mentoring and tutoring on health lit-eracy in the Newark and Atlantic City areas. In theseprograms, teenagers are trained as mentors to workwith younger children to improve their reading skills.An important component of the program is the inte-gration of health-related information.

n Horizon Walks for Health Campaign. This community/corporate wellness program was developed in partner-ship with the American Heart Association and AmericanDiabetes Association and is designed to encouragedaily moderate exercise and portion control by deliv-ering a consistent message at public, corporate andschool events.

n Horizon Health Kit. Launched in July 2003, theHorizon Health Kit is designed to educate New Jerseyresidents about the importance of exercise and healthyeating. The kit includes a BMI chart, a pedometer anda pocket calendar for recording activities. It is beingdistributed at health-related events throughout thestate. The Health Kit is also available in a low literacy version.

n Horizon Health Future. Through a partnership withthe New Jersey Network (NJN), a public television andradio network, Horizon provided the necessary hard-ware and software to link thousands of teens andadults to approximately 400 educational modulesthrough Boys and Girls clubs in several New Jerseycommunities. The modules included health literacyand other topics. The program also provided fundingfor participating teens to develop their own videos onhealth-related topics, including obesity.

Horizon Blue Cross Blue Shield of New Jersey

In the essay he authored for this report, Dr. Eric J. Berman,Medical Director for Horizon Blue Cross Blue Shield ofNew Jersey writes, "Although several factors contribute tothe development of obesity, the key to controlling it froma public health standpoint lies in uniting public and privateresources …" Horizon’s response to the complex problemof obesity embodies this philosophy by approaching theissue from two angles — as a chronic health problemaffecting the lives of many of its members, and as amajor public health crisis, with implications far beyondHorizon’s membership.

Enhancing Community Resources

As part of its strategic planning efforts, Horizon developedand launched the World Class Clinical Quality initiative in2002. Part of this initiative included identifying the keyissues affecting the health and well-being of New Jerseyresidents and developing strategies to address these issuesin ways that produced quantifiable, replicable and sustain-able results. To address the issues of overweight and obe-sity, Horizon designed and implemented several programsthat focus on education and behavior modification.

Horizon’s programs also have a special emphasis on healthliteracy, defined as the ability to read, understand, and acton health information. Horizon’s community-based pro-grams include the following:

n Shape It Up Program. In conjunction with the ErnestMario School of Pharmacy at Rutgers University,Horizon recently began an initiative to provide obesi-ty intervention workshops in New Jersey public ele-mentary schools. The program and its accompanyingmaterials were designed by state-certified teachers tomeet the requirements of the New Jersey Core HealthCurriculum. More than 350 schools have requestedthe program, and it will be presented to 150 schoolsduring its first year. More information is available atwww.bcbsnj.com/shapeitup/index.asp.

Nearly half of adults nationwide areconsidered to have low levels of healthliteracy, which directly impacts theirability to understand food labels andnutritional guidelines, as well as understandand follow medical advice related totheir own or their children’s weight.15

Estimates of the cost of low health literacy are approximately $84 billion,primarily in the form of extra physicianvisits and longer hospital stays.14


Employers and Health Plans Weigh Benefits andRisks of Weight Loss Surgery

For individuals classified as morbidly obese, generally defined ashaving a BMI of 40 or greater, non-surgical treatment options haveshown little success in achieving substantial or sustained weightloss. Bariatric surgery has long been viewed as a last resort for themorbidly obese, as well as moderately obese individuals (BMI of 35or greater) who have one or more co-morbid conditions, but it isbecoming an increasingly popular procedure.

Over the last decade, the number of weight loss surgeries performedhas skyrocketed from less than 20,000 in 1992 to over 100,000 in2003. The growing popularity of bariatric surgery has many con-cerned about the procedure, its effectiveness, costs and risks.

Background, Efficacy and Risks

The National Institutes of Health (NIH) guidelines for bariatric surgerywere published in 1991 and have remained unchanged since then.The guidelines state that surgery should be considered for individu-als with a BMI of 40 or greater (or greater than 35 with a co-morbidcondition), who have failed under other treatments and are motivat-ed to lose weight.

A large number of studies have demonstrated that bariatric surgeryis effective in helping morbidly obese individuals achieve substantialweight loss. For example, a recent evidence review by the Blue Crossand Blue Shield Association Technology Evaluation Center (TEC)found that “the evidence is sufficient to conclude that surgeryimproves health outcomes for patients with morbid obesity as com-pared to non-surgical treatment.”

It is important to note that the TEC evaluation draws heavily from asingle study that included over 1,000 patients, the majority of whom

were followed for at least five years post-surgery. The other studiesin the evaluation were smaller but corroborate the findings from thelarger study. However, given these data limitations, TEC cautionsthat “it is not possible to draw conclusions as to the relation of incre-ment of weight loss to increment of improvement in health outcomemeasures,” nor is it possible to identify a weight threshold for suc-cess of the surgical procedure. Some of the concern over the impactof weight loss surgery on co-morbid conditions may be alleviated bya recent review in the Journal of the American Medical Association,which found effective weight loss and significant improvement in co-morbid conditions, including diabetes and hypertension, amongmorbidly obese patients undergoing bariatric surgery.

There is somewhat conflicting evidence over the risks faced by indi-viduals who undergo bariatric surgery. One recent study found thatone in 50 surgery patients died within 30 days of surgery, while otherstudies have reported rates of one in 200 or one in 300. Additionalrisks from surgery include pneumonia, infection, anemia and othernutritional deficiencies.

Employer and Health Plan Response

While uncertainty remains about the relative risks and benefits ofweight loss surgery, most plans do cover the procedure for membersmeeting the NIH criteria, but this may be changing. Within the lastyear, two major health plans — Blue Cross and Blue Shield of Floridaand Nebraska — have announced that they are dropping coveragefor bariatric surgery and some have speculated that other plans mayfollow suit. With an average cost of $30,000 and extensive follow-upcare required, employers and health plans are questioning whetherthe cost is in line with the benefits.

If the Medicare Coverage Advisory Commission gives its approval forweight loss surgery, there may be growing pressure on commercialinsurers to cover the procedure. But regardless of Medicare’s deci-sion, health plans, providers and employers are continuing to devel-op evidence-based policies that maximize the potential benefits ofweight loss surgery while minimizing the risks. One increasingly pop-ular approach is designating Centers of Excellence — typically facil-ities that have high weight loss surgery volumes or can otherwisedemonstrate high quality. Another approach was recently taken by aconsortium of New York health plans and providers who developeda set of consensus guidelines for selecting the most appropriatepatients, the most experienced surgeons and the best-equippedfacilities across the state.

Sources: H. Buchwald et al. Bariatric Surgery: A Systematic Review and Meta-Analysis. JAMA 2004; 292:1724-1737Technology Evaluation Center. “Special Report: The Relationship between Weight Loss and Changes inMorbidity Following Bariatric Surgery for Morbid Obesity”. Volume 18, No. 9, September 2003Flum DR, Dellinger E P. “Impact of gastric bypass operation on survival: A population-based analysis"”Journal of the American College of Surgeons. October 2004. See, for example, Pope GD, Birkmeyer JD, Finlayson SR. National trends in utilization and in-hospital out-comes of bariatric surgery. J Gstrointest Surg 2002;6:855-860;discussion 861 or Commonwealth ofMassachusetts Betsy Lehman Center for Patient Safety and Medical Error Reduction Expert Panel onWeight Loss Surgery Executive Report August 4, 2004.Medicare Coverage Advisory Commission “Summary of Evidence - Bariatric Surgery - November 4, 2004”Available at: www.cms.hhs.gov/mcac/id137f.pdf

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Source: American Society for Bariatric Surgery, www.asbs.org

Figure 5. Trend in Bariatric Surgery Use (1992-2003)

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Resources for Horizon Members

Horizon has also implemented weight management toolsand programs designed specifically for its own membersand is continuing to develop and expand these programs as part of its World Class Clinical Quality initiative. In spring 2004, Horizon launched a pilot WeightManagement Health and Wellness Education Program. The program is currently available to fully-insured HMOmembers who are identified through medical and pharma-ceutical claims analysis. Identified members are furtherclassified into high- and low-risk groups by a predictivemodeling tool that looks at past costs and utilization.

All identified members are notified of their eligibility forthe Weight Management Health and Wellness EducationProgram by mail and are given the opportunity to optout. Those who remain in the program receive quarterlymailings containing educational materials and weight losstools such as a pedometer, a food diary and a tape measure.The materials promote weight management by encourag-ing healthy eating behaviors combined with a moderateexercise regimen. Participants learn how to measure BMI,choose healthier meals, control blood pressure and reducecholesterol. All identified members also have free 24-houraccess to health professionals via a telephone counselingline to help them create and follow through on a cus-tomized treatment strategy. Horizon plans to add groupeducational seminars to the program in 2005.

Members identified as high risk receive additional services.These members are contacted by a registered dietician and

n Poster and Brochure Campaign. These award-win-ning materials were created in partnership with theAmerican Heart Association and the American DiabetesAssociation and are targeted toward families and chil-dren. They are also available in a low literacy version.

Improving Employee Health

After learning that almost half of its employees had atleast one chronic disease risk factor, Horizon launched anemployee wellness program with its joint venture partner,Atlanticare, in southern New Jersey. The program givesemployees time to engage in physical activity and pro-vides incentives and places for them to do so. The programalso includes regular testing of blood pressure, bloodsugar and cholesterol.

Shaping the Policy Agenda

Consistent with its philosophy of addressing obesity byjoining public and private resources, Horizon has taken aleadership role in focusing the health policy agenda in NewJersey on the growing epidemic of obesity. Horizon sponsorsan annual Health Policy Forum each October, which gath-ers policymakers, clinical experts and health leaders to dis-cuss health policy, obesity and health literacy, as well asother important issues. At last year’s forum, Horizonlaunched the New Jersey Health Policy Consortium, whichit hopes will bring together diverse expertise and influencethe health policy agenda in New Jersey.

While the Horizon/Alliance program is voluntary, almost all employees participatedin the pilot, and the feedback and resultshave been encouraging. Out of 48employees with a BMI of 25 or more, 25reduced their BMI over a one year period.The employee wellness program has sincebeen expanded to two additional sites,with plans to expand enterprise-wide andeventually introduce the program toHorizon’s employer groups.


Kaiser Permanente

With an estimated 4.4 million overweight or obese adultmembers out of 7 million total adult members and datashowing that the total cost of care for obese members was44 percent higher than for healthy weight members,Kaiser Permanente (KP) knew it had to take a broad, pub-lic health approach to combat this problem. In January2002, the Care Management Institute (CMI) of KaiserPermanente launched the Weight Management and Obesity(WMO) initiative to address the growing epidemic ofoverweight and obesity. The WMO initiative includes fiverelated components:

n Establishing appropriate clinical management tools, n Disseminating successful practice strategies,n Building community partnerships, n Establishing a research network, andn Influencing legislation and public policy.

The short-term goals of the initiative are to document theexisting programs in place across KP, implement weightmanagement strategies in the primary care setting, andbegin to review and identify additional interventions.Longer-term goals include developing metrics to quantifythe effectiveness of interventions, standardizing programsand enhancing physician and member skills through toolsand education. Additional longer-term goals include theinstitution of effective public policy targeting preventionof overweight and obesity and fostering the developmentof community based weight management programs.

Kaiser Permanente’s integrated delivery system and infor-mation technology systems provide a clear advantage inimplementing and evaluating clinical approaches toweight management, and Kaiser’s regional structure pro-vides a natural laboratory for testing a wide range ofapproaches to this epidemic.

Weight Management and Obesity Initiative

Clinical ManagementKP’s multi-tiered approach to the obesity epidemic wascreated with the clear intention of refraining from “over-medicalizing" a problem that has causes and implicationsfar beyond the medical. Nevertheless, clinical managementis the glue that holds KP’s Weight Management andObesity Initiative together.

complete a comprehensive health assessment over thephone. The assessment is used to develop an individualweight loss plan for the member. These members arethen contacted by the dietician every one to three weeksto assess progress.

Horizon is also currently implementing a small pilot studyof the Weigh to Live program, a comprehensive, medicallysupervised 16-week commercial weight loss program. Thepilot, which is being limited to 100 members (membersreceive a discount on the program and a rebate uponcompletion), includes one-on-one and group counseling,regular lab tests, healthy meals, and a gym membershipwith access to a personal trainer. The pilot will be evaluat-ed in late 2005. If successful, Horizon may offer largerdiscounts for the program across its membership.


Horizon covers bariatric surgery for members with a BMIgreater than 35 with one or more co-morbidities, or greaterthan 40 with no co-morbidities. Candidates must also completea behavioral evaluation and must demonstrate that othermeaningful attempts at weight loss have failed. Weightloss drugs are covered when prescribed by a physician.

Additional Efforts

With funding from Shape-Up America, Horizon hasdeveloped and distributed a web-based pediatric assess-ment tool to measure overweight and obesity risk inchildren, for whom adult BMI standards are not appropri-ate. The assessment tool is available to all physiciansboth inside and outside of Horizon’s network. Horizonbelieves this is the first web-based tool of its kind.

Horizon’s ongoing efforts to address overweight and obe-sity are coordinated through the Horizon Health Council,an internal body that includes representatives from acrossthe organization. The Council is currently looking at waysto expand the employee health program to additional sitesand to Horizon employer groups and is also evaluatingreimbursement and incentive models for both networkphysicians and Horizon members to encourage weightmanagement and weight loss.

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sheets and charting forms to support care delivery andeffective conversations with patients and families. Weightmanagement messages have been incorporated into KP’sEducational Theatre production, Zip’s Great Day, andweight management posters are distributed to schoolswhere Educational Theatre productions are staged.

Establishing a Research NetworkA research network comprised of 30 KP scientists has beenestablished to create and disseminate new knowledge andmake KP’s weight management programs more effective.In addition, the Kaiser Permanente Garfield MemorialFund has selected 15 KP existing and proposed interven-tions for funding as part of its Weight ManagementResearch Initiative. Published results of these initiativeswill be available in the future.

Influencing Legislation and Public PolicyA key component of the public health model involvescollaborating with a variety of public and private partnersto address societal issues that contribute to the obesityepidemic. As part of this effort, KP’s Care ManagementInstitute (www.kpcmi.org) has forged a strong relationshipwith the Division of Nutrition and Physical Activity of theCenters for Disease Control (CDC) to identify practicalsolutions that can be applied in the primary care settingand translate research into clinical recommendations. TheCare Management Institute was also one of the sponsorsof a major national roundtable discussion in August 2003titled “Prevention and Treatment of Overweight andObesity: Toward a Roadmap for Advocacy and Action"which brought together researchers, health plans, commu-nity organizations and others to identify priorities foradvocacy and action.

To ensure that KP clinicians and administrators are knowl-edgeable about obesity and the KP programs available foroverweight and obese members, KP-CMI has developedthe CMI Weight Management Source Book, which outlineskey elements of KP’s weight management and bariatricsurgery programs. KP has collaborated with HealthPartnersto complete an update of the literature and is now trans-lating that evidence for clinicians and members. Thisinformation will guide program design and the creationof practice recommendations.

KP’s weight management efforts are closely tied to sys-tem-wide data initiatives, especially an initiative toimplement electronic medical records (EMR) in all regionsover the next three years. KP hopes to institute near uni-versal BMI measurement of all KP enrollees, especiallychildren, to assess trends over time in order to interveneearly and move toward effective prevention strategies. Inaddition, the availability of BMI measures supports con-versations between clinicians and patients about weightand health. Some regions have been moving rapidly toimplement BMI as a vital sign, with rates exceeding 50percent, while other regions have been proceeding morecautiously. It is expected that the implementation of theEMR will accelerate adoption of BMI as a vital sign.

Successful Practice DisseminationPractice dissemination is accomplished through severalstrategies, including workshops and motivational inter-viewing training for clinicians. Dr. Scott Gee, MedicalDirector for Prevention and Health Information in KP’sNorthern California Region, has developed a training program for clinicians on how to help patients changebehavior based on the Stages-of-Change Model.16 He hasused the program to train clinicians in several KP regions.To help physicians communicate with their patients aboutweight management, KP has also created and disseminateda template to guide communications and prioritize discus-sion based on the amount of time available (one-minute,three-minute and ten-minute periods).

Building Community PartnershipsKP’s Community Benefit Program works with communityclinics and safety net providers to help them addressoverweight and obesity among their patients by providingtraining for clinicians and tools, such as BMI wheels, tip

Kaiser Permanente’s integrateddelivery system and informationtechnology systems provide a clearadvantage in implementing andevaluating clinical approaches toweight management, and Kaiser’sregional structure provides a naturallaboratory for testing a wide rangeof approaches to this epidemic.


single-session classes on physical activity and another onweight management, which are intended to help themember understand the KP and non-KP resources that areavailable to them and develop personalized weight man-agement and exercise programs. These programs are avail-able at no additional charge.

Lower-risk children are enrolled in the national KidShape®

program while high-risk children and those with co-mor-bid conditions are enrolled in a Kaiser program that com-bines a multi-session educational program with a low-calorie diet.

KP Northern California’s Health Education Department hasalso developed counseling protocols to clinical health edu-cators in counseling patients about weight loss and weightmanagement issues. KP Northern California is nearingcompletion of multiple evaluations of its adult and pedi-atric obesity programs.

KP Southern CaliforniaKP Southern California offers several weight managementprograms, ranging in length from one session to sixmonths or longer. In addition, KP Southern California oper-ates a freestanding fee-for-service metabolic obesity center.KP also offers weight management programs for adoles-cents and their caregivers, which consist of one or two ses-sions and address reasons for weight gain and strategies forhealthy eating and increasing physical activity.

KP OhioKP Ohio members can access discount programs, such asWeight WatchersTM that offer member discounts for groupand online programs The KP Fitness program offers dis-counted memberships to fitness centers and gyms.

KP GeorgiaKP Georgia members have access to a variety of weightmanagement resources and programs. These include class-es such as Managing Your Weight (adult six-sessionclass), Operation Zero (eight-session class for childrenage 11-17), The Art of Cooking Healthy, and WorkingTowards Wellness. Other resources include the BehavioralHealth Eating Disorder program, discounted rates forhealth clubs and commercial weight loss programs, aswell as a variety of online resources.

Regional Weight Management Programs

Complementing the CMI’s model, KP continues to initiateand test interventions for various populations regionallywith the goal of improving these programs as the knowl-edge base increases. Many of KP’s programs have been inplace for several years, and a number of evaluations areunderway to assess their effectiveness. All regions includebariatric surgery as a covered benefit for members whomeet specific criteria. The programs are described below.

KP ColoradoKP Colorado offers multiple programs including WeightConnections, a six-week group visit model for adults thatcan be supplemented by small group booster sessionsduring weight maintenance. The program has enrolled 360participants during its eight-month existence. An evaluationframework is currently being developed. Additional pro-grams include Family Connections, a multi-session groupvisit program for parents of children under 12 years old,and Bariatric Connections, a twelve-session pre-bariatricsurgery preparation course. KP Colorado is currently pilot-ing a telephone-based triage and weight managementsystem with encouraging early results.

KP Mid-Atlantic StatesKP’s Mid-Atlantic region has offered dietician-led classesin weight management for over six years. Class topicsinclude dietary change, factors that influence eating andexercise, and beliefs and attitudes about weight. The pro-gram has not been formally evaluated.

KP NorthwestKP Northwest offers three weight management programs:a self-study program titled Weight Loss Basics, a five-week educational program, and a twelve-week program.The five-and twelve-week programs provide informationon behavioral modification, diet and exercise. Participantsin these programs lose a mean of 1.1 pounds per week.

KP Northern CaliforniaKP Northern California adult members have access to sever-al programs, ranging from web-based educational pro-grams to the Lifestyle and Weight Management Program,a multi-session class led by a team consisting of a dieti-cian, a counselor, and a health educator and/or an exer-cise physiologist. KP Northern California also offers

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KP HawaiiMembers have access to a variety of programs includingFitter Me, which is an individual or group-based inter-vention available since 1990 that enrolls 128-337 membersper year. In addition, Weight WatchersTM has been avail-able since 2002 with approximately 75-100 enrollees peryear. KP Hawaii is also currently piloting FitZone, a pedi-atric program for children ages 9 to 15.

Group Health CooperativeGroup Health Cooperative members have access to severalweight management programs that can be tailored tomeet individual needs. The programs include mealreplacement, weekly classes, individual contact with ahealth educator (by phone or in person), or a combinationof these components.

Premera Blue Cross

Employers bear a significant portion of the costs associat-ed with obesity and obesity-related conditions in the formof reduced productivity and higher health and disabilityinsurance costs. In 1994, obesity-related health problemscost U.S. businesses almost $13 billion, including $10billion in health and life insurance expenditures, $2 billionfor sick leave and $1 billion for disability insurance.17 The2001 Surgeon General’s report on obesity indicates thatthe overall costs of obesity totaled $117 billion, includingboth direct costs for prevention, diagnosis and treatmentas well as indirect costs associated with lost wages andfuture earnings. Not surprisingly, employers are increas-ingly looking to health plans for answers.

Concerned about employee health and rising healthcarecosts, Microsoft, one of the nation’s largest companies,took action. Even though employees of this large softwarecompany tend to be younger and healthier than averagefor large U.S. corporations, the company was not immuneto the larger national trend. As a result, Microsoft devel-oped a pilot weight management program in 1999. Afterreviewing the pilot results and implementing several plandesign modifications, a comprehensive weight manage-ment program was rolled out to all U.S. employees onJanuary 1, 2002.

One year later, Premera Blue Cross joined Microsoft inits efforts to manage rising healthcare costs by assumingresponsibility for healthcare claims management for allU.S. Microsoft employees. Based on their commitment tosupporting wellness programs, Premera was able to fur-ther support Microsoft’s efforts to offer a comprehensiveweight management program to achieve positive resultsfor its participants as well as for Microsoft.

Premera’s Approach: A Collaborative, Physician-Driven Model

Roki Chauhan, M.D., Premera’s Vice President for MedicalServices and Medical Director for Quality, describes the

Premera was awarded the Microsoftaccount in part because of its approachthat supported employee wellness andcomprehensive weight and obesitymanagement programs.


Tiered Approach to Weight Management

Spurred by the success of the Microsoft program, growinginterest from other employer groups and disturbingnational trends, Premera brought together a task force toaddress overweight and obesity issues. In early 2004,under the leadership of Shelly Smith, M.N., Director ofQuality, and Corinne Bell, D.O., Western WashingtonMedical Director, Premera formed a ComprehensiveObesity Strategy Team to define, develop and implementa strategy for members and employers. Team membersrepresented medical directors, clinical quality, diseasemanagement, benefit design, actuarial and product strat-egy development. The team addressed the impact of obesi-ty, related quality of life issues, and the impact on medicalcosts. The result is a product that responds to employerrequests for obesity strategies for their overweight andobese employees.

A five-tier program was designed to balance coveragewith choice and to respond to varying levels of employerinterest in obesity and weight management. The compo-nents of the five tiers range from basic tools and incentivestargeted toward prevention and encouraging healthylifestyles to a comprehensive obesity benefit offeringmedical, nutritional, behavioral and surgical services spe-cific to obesity. Bariatric surgery is only offered at thehighest level, and then only under strict criteria and withintensive behavioral modification counseling. Weight lossdrugs are not covered at any level.

Tier 0 — Basic BenefitThis level is offered to all fully-insured members at noadditional cost and includes online health information onfitness, weight loss, and men’s and women’s health, aswell as discounted memberships for weight loss programsand fitness clubs.

Tier 1 — Health Management BenefitThe next level adds a Health Management Benefit, whichprovides limited coverage for community wellness classessuch as weight management and smoking cessation.

Tier 2 — Health Risk ManagementTier 2 offers a more targeted approach to addressing over-weight and obesity through Premera’s vendor Summex.Employees who work for employers that purchase this

Microsoft program as a medical and surgical benefit thatis “physician driven" but also uses a team approach.Employees and their covered spouses/same-sex domesticpartners are eligible for the weight management programif their BMI is greater than or equal to 30 or if they havea BMI of 27 with two or more of the following conditions:

n Congestive Heart Failuren Coronary Heart Diseasen Diabetesn Hyperlipidemian Hypertension

Participation is voluntary, and members must be assessed bytheir primary care physicians to determine if they qualify.

Members meeting the criteria are enrolled in approvedweight management programs that provide services for atleast 24 weeks and sometimes longer. To meet Premera’sand Microsoft’s standards, a weight management programmust provide medically supervised care in the areas ofnutrition, behavioral therapy and personal fitness train-ing. Once a member qualifies for a weight managementprogram, the member is assessed and a comprehensiveprogram is developed by the weight management team.The programs typically involve an intensive phase, whichincludes a minimum of ten sessions with a physician, apersonal fitness trainer, a dietician and a behavioralhealth therapist. Following the completion of the intensivephase, a three-month maintenance phase begins, whichfocuses on follow-up with professionals on exercise,nutrition and medical oversight on a less rigorous butstill regular schedule.

Early Challenges and Results

With an enrollee base dispersed throughout the U.S., oneinitial challenge for Premera was building and maintain-ing a network of qualified weight management programs,especially outside of its home state of Washington.Programs meeting all of the criteria were sometimes diffi-cult to find, and some of the programs that did exist wereoften unprepared to handle the administrative complexi-ties of insurance reimbursement. To address this issue,Premera worked to design simplified claims and reportingrequirements for these programs. As of December 2004,sixteen programs in twelve states have been approvedand contracted to provide weight management forMicrosoft employees.

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option will be provided with a Health Risk Assessment(HRA) tool for the identification of health risk factorsincluding obesity. Those determined to be at-risk willreceive further assessment as well as telephonic coachingand other targeted interventions.

Tier 3 — Intensive Weight ManagementFor employer groups who desire a specific BMI-focusedprogram, the intensive weight management option identi-fies overweight or obese members through a health riskassessment tool. Identified members receive condition-specific telephonic counseling and coaching along withtools to support their weight loss goals.

Tier 4 — Obesity Benefit For employers such as Microsoft that desire a comprehen-sive obesity benefit, Premera has created a template to pro-vide physician-directed obesity and weight managementservices that may include medical visits, nutritional counsel-ing, physical therapy and surgical interventions. Candidatesfor bariatric surgery, a covered benefit at this level, mustmeet specific criteria and undergo significant behaviormodification counseling.

Toward the Future

Based on the success of Microsoft’s program, Premera wasable to develop a Comprehensive Obesity Strategy to meetthe needs of other employer groups and their employees.This work demonstrates that collaborative approaches arecritical in shaping clinically-based benefit packages andensuring that the right care is provided to employees whoneed treatment for overweight and obesity. Continualassessment, monitoring and improvement of the programswill occur so that positive outcomes can be achieved.

Tier 4 – Obesity Benefit

Tier 3 – Intensive Weight Management

Tier 2 – Health Risk Management

Tier 1 – Health Management Benefit

Tier 0 – Basic Benefit

Premera Comprehensive Obesity Strategy

Expert Panels’ Recommendations Set Important Standards

By establishing review panels to evaluate research studies on healthinterventions, the federal government provides leadership and directionin disseminating evidence-based practices. The U.S. PreventiveServices Task Force (USPSTF) is an independent panel of experts in pri-mary care and prevention, convened by the government and housed atthe Agency for Healthcare Research and Quality, to review systematical-ly the evidence of effectiveness and develop recommendations for clin-ical preventive services. The Task Force on Community PreventiveServices (TFCPS) is also an expert panel, appointed by the governmentand housed at the Centers for Disease Control and Prevention, whosemission is to provide leadership in the evaluation of community, popula-tion and healthcare system strategies to address a variety of publichealth and health promotion topics. The USPSTF evaluates studies onclinical interventions while the TFCPS evaluates interventions that occuroutside the clinical setting, are delivered to groups rather than individu-als, or are delivered by persons other than healthcare providers.

U.S. Preventive Services Task Force:Recommendations on Screening and Counseling for Obesity in Adults

In a December 2003 Annals of Internal Medicine article, the USPSTFrecommended that physicians screen all adults for obesity and offerintensive counseling and behavioral interventions to all obese adults.

USPSTF members conducted a thorough review of the literature andconcluded:

n There is fair to good evidence that high-intensity counseling pro-duces modest but sustained weight loss in obese adults. Highintensity interventions yielded an overall mean sustained (18month) weight loss of three to five kilograms. In one of the stud-ies the panel deemed reliable, 30 percent of participants lost atleast 5 percent of their body weight and kept it off for a year. Inanother, 38 percent of people in the intervention group lost anaverage 7 percent of body weight;

n There is no direct evidence that intensive diet and nutrition coun-seling and behavior modification lowered mortality or morbidity,but there is strong indirect evidence of impact based on interme-diate outcome assessments (improved glucose metabolism,lower lipid levels, etc.);

n There is insufficient evidence that moderate- or low-intensitycounseling, together with behavioral intervention, yielded sus-tained weight loss; and

n There is insufficient evidence to indicate whether people who areoverweight but not obese benefit from high intensity weight lossprograms.

The group defined obese adults as those with a BMI of 30 or above.2

For screening adults, it viewed the BMI measure as “easy…highlyreliable, and closely correlated with adult body fat.” It also recom-mended that clinicians measure waist circumference and waist-to-hipratio. Both screening measures capture increased cardiovascular risk


associated with central adiposity (concentration of body fat in themid-section) and metabolic syndrome (a cluster of risk factorsincluding hypertension, high triglycerides, blood clots, glucoseintolerance and insulin resistance).

The expert panel defined counseling intensity by the frequencyand the type, modes and mix of interventions. More than one per-son-to-person (individual or group) session per month for at leastthe first three months of treatment constitutes a high intensityintervention. One session per month was defined as a moderate-intensity intervention.

Successful interventions typically included at least two and prefer-ably three of the core components of treatment — diet, exerciseand behavioral therapy. Consistently across the studies the panelevaluated, diet combined with physical activity counseling result-ed in greater reduction of weight and abdominal fat than eitherapproach used alone. More information on the USPSTF and itsobesity screening and counseling recommendations is availableat http://www.ahrq.gov/clinic/uspstfix.htm.

Task Force on Community Preventive Services:Recommendations for Promoting Physical Activity

The TFCPS issued recommendations on interventions to promotephysical activity in the American Journal of Preventive Medicine in2002. Physical activity is associated with longer, healthier life as wellas reduced incidence of certain diseases, particularly high bloodpressure, diabetes, heart disease and obesity. However, despitethe benefits of regular physical activity, many Americans lead asedentary lifestyle: only 25 percent of adults and 27 percent of highschool students get moderate exercise regularly.

To better understand what strategies work best in promoting physi-cal activity, the Task Force examined research on effectiveness ofinformational approaches, behavioral and social approaches, andenvironmental and policy approaches to increasing physical activi-ty. They classified the evidence of effectiveness as either “strong,”“sufficient,” or “insufficient.”

The Task Force found strong evidence in support of:

n Community-wide informational campaigns, which yielded a 5percent increase in the proportion of people who are physical-ly active and a 16 percent increase in energy expenditure;

n Individually-adapted health behavior change (e.g., individualgoal-setting and tailored behavioral reinforcement), which gen-erated a median 35 percent increase in physical activity;

n School-based physical education, which generated an 8 per-cent increase in aerobic fitness;

n Non-family social support (e.g., walking groups), which result-ed in as much as a 44 percent increase in time spent beingphysically active; and

n Increased access to places for physical activity, which yieldedas much as a 25 percent increase in the number of people whoexercise three or more times a week.

The Task Force is currently evaluating the effectiveness of trans-portation policy and infrastructure changes on increasing physicalactivity as well as urban planning approaches.

In many cases, the TFCPS found multi-component strategies tobe effective. The Task Force’s findings are summarized below.More information on their recommendations is available atwww.thecommunityguide.org.

Sources: McTigue et al. Screening and Interventions for Obesity in Adults: Summary ofthe Evidence for the US Preventive Services Task Force. Annals of InternalMedicine Dec. 2003;139:933-949Task Force on Community Preventive Services. Recommendations to IncreasePhysical Activity in Communities. American Journal of Preventive Medicine2002;22(4S):67-72

Intervention Recommendation

Information Approaches

Community-wide campaigns Recommended – Strong evidence

“Point of Decision” prompts Recommended – Sufficient evidence

Classroom- based health education Insufficient evidence to determine effectiveness

Mass media campaigns Insufficient evidence to determine effectiveness

Behavioral and Social Approaches

Individually-adapted health behavior change

Recommended – Strong evidence

Health education with TV/Video game turnoff component

Insufficient evidence to determine effectiveness

College-age physical/health education

Insufficient evidence to determine effectiveness

Family-based social support Insufficient evidence to determine effectiveness

School-based physical education Recommended – Strong evidence

Non-family social support Recommended – Strong evidence

Environmental and Policy Approaches

Creation and/or enhanced access to places for physical activity combined with informational outreach activities

Recommended – Strong evidence

Transportation policy and infrastructure changes to promote non-motorized transit

In progress

Urban planning approaches – zoning and land use

In progress

Table 2. Recommendations for Promoting Physical Activity

PLAN PROFILES 41

n The physical examination including: BMI measurementand plotting on graph, assessment and interpretation ofgrowth patterns, physical conditions associated withoverweight and breastfeeding observation;

n Management and/or referral of children/adolescentswith a medical condition related to overweight;

n Basic dietary and physical activity counseling to pro-mote healthy lifestyles;

n Development of systems that assist in the utilization ofappropriate members of the health care team to ensurecomprehensive care of the patient and the family;

n Assessment and utilization of community resources tohelp prevent and support treatment plans for overweightchildren and adolescents;

n Community-oriented care with focus on the healthneeds of all children within a community, particularlyunderserved populations;

n Psychosocial and developmental screening techniques;

n Behavioral counseling and referral;

n Health promotion, disease prevention, and anticipatoryguidance of adolescents; and

n Psychosocial issues, such as peer and family relations,depression, eating disorders, substance abuse, suicideand school performance.

In addition, the CME program is designed to help practi-tioners develop cultural sensitivity toward the patientpopulation they serve and understand their own personalbiases and prejudices related to weight, food, breastfeedingand physical activity.

The American Academy of Pediatrics, the AmericanAcademy of Family Physicians, and the California MedicalAssociation have approved the Childhood Obesity programfor 1.5 hours of CME credit. These organizations providedvaluable input into the content development of the program.WellPoint will initially pilot the program — free of charge —with its network physicians starting in Georgia andCalifornia by the first quarter of 2005. WellPoint will thentest the user-friendliness of the program and measure itsimpact on physician knowledge and attitudes. The results ofthe evaluation will inform revisions in the content as neededbefore the program is rolled out nationwide later in 2005.

WellPoint Health Networks

In July 2002, the American Academy of Pediatrics publisheda study in the journal Pediatrics that reported a high interestamong pediatric primary care practitioners in additionaltraining on childhood overweight and obesity, especially inthe areas of patient counseling and assessment of risk. Tohelp address these issues, WellPoint launched a project tocreate a comprehensive web-based CME program. Whencompleted, the CME program will form an important com-ponent of WellPoint’s multi-faceted approach to addressingchildhood overweight and obesity.

Childhood Obesity CME Program

The 2002 Pediatrics study found that physicians, pediatricnurse practitioners and other providers fell short of recom-mended practice guidelines for evaluation of overweightchildren and adolescents. While most providers routinelyevaluated blood pressure, a minority of those surveyedroutinely looked for orthopedic problems, insulin resistanceor sleep disorders, and less than 10 percent followed all rec-ommendations for medical history and physical examination.In response to these findings and the recent growth in web-based CME programs, WellPoint partnered with Dr. Slusser,Assistant Clinical Professor of Pediatrics at UCLA and anationally recognized expert on childhood nutrition, theAmerican Academy of Pediatrics, the California MedicalAssociation and other family physicians and pediatriciansto develop a CME program to provide health care practition-ers, including family physicians, pediatricians and pediatricand family nurse practitioners, with the knowledge, attitudeand skills necessary to help them prevent, detect, assess andmanage overweight and obese children and adolescents.

In addition to helping practitioners expand their knowledge ofobesity, evidence-based preventive interventions and the med-ical and psychosocial conditions associated with overweightand obesity, specific skills covered in the program include:

n The medical interview, focusing on the family, psychoso-cial history, diet and physical activity/inactivity as wellas a focused review of symptoms for medical conditionsassociated with overweight;

While most providers routinely evaluatedblood pressure, a minority of those sur-veyed routinely looked for orthopedic prob-lems, insulin resistance or sleep disorders,and less than 10 percent followed all recom-mendations for medical history and physicalexamination.


members and are available for purchase by self-insuredgroups. Currently, there is no free-standing healthimprovement program for obesity. However, many of thehealth improvement programs include significant weightmanagement modules.

WellPoint’s health improvement programs are led by healthcoaches that include RNs, dieticians, social workers, exercisephysiologists and other health professionals. As part of theinitial session, the health coach calculates the member’s BMIbased on self-reported height and weight. The frequency offollow-up phone contact with the member varies based onthe individual’s BMI and their motivation to change asassessed by the health coach. Individuals with a BMI below40 receive ongoing coaching and counseling to help themdevelop and carry out a strategic diet and exercise plan.WellPoint is currently testing a new “healthy weight module"for individuals with a BMI of 40 or greater. The moduleincludes more extensive information on diet and exerciseand more frequent follow-up by the health coaches. An eval-uation of the healthy weight module is currently underway.

All of the content for WellPoint’s health improvementprograms, as well as web-based and printed materials, isdeveloped centrally and approved by a team of physiciansand other providers. Educational materials include anassessment tool for the health coaches to measure risk fac-tors and readiness to change, and over 50 “teaching sheets"on topics ranging from healthy eating to exercise andbehavior modification. The teaching sheets are used byhealth coaches to help guide their sessions with members.

Members have access to discounts for weight loss programs,vitamins and other health resources (specific discount programsvary by market). In addition, employer groups can accessWellPoint’s Healthy Weight and Nutrition program, a fee-based worksite wellness program led by a registered dietician.


Coverage of weight loss surgery and medications variesacross WellPoint’s markets. However, WellPoint is currentlyin the process of identifying and designating Centers ofExcellence for weight loss surgery that meet specific criteriafor quality. WellPoint’s Blue Cross of California plan hasalready identified centers in California that meet its criteriaand have been available to certain accounts since January2005. WellPoint is currently evaluating facilities in Georgia(Blue Cross and Blue Shield of Georgia) and expects to startevaluating facilities in Wisconsin (Blue Cross and BlueShield of Wisconsin) to launch Centers of Excellence pro-grams in these states shortly.

Other Resources Targeting Pediatric Obesity

Over the past two years, WellPoint has developed and dis-tributed several tools to help physicians and familiesaddress childhood obesity, including:

n Healthy Habits for Healthy Kids. This bilingual printand web-based guide was developed in collaborationwith the American Dietetic Association to help doctors,nurses and other health care professionals communicatewith parents and families about childhood obesity. Theguide stresses family participation and provides practi-cal strategies for engaging the family in healthy eatingand physical activity.

n Get Up and Get Moving. This multilingual programincludes resources for both parents (available in Spanish,Vietnamese and Russian) and providers and is targetedat California Medicaid and SCHIP members and theproviders who serve them. The provider toolkit includesa BMI chart, Expert Committee Recommendations forassessing and treating overweight children, and aCommunity Resource Center contact sheet. The parenttoolkit is written at a low literacy level and includes tipson healthy eating and exercise, a food guide pyramidand a Community Resource Center contact sheet.

n Physician Desk Reference Tool. WellPoint collaboratedwith Dr. Slusser to develop this resource to give physiciansquick access to current data from the scientific literatureand expert work groups related to childhood obesity. Likethe CME program, the desk reference tool was created tohelp providers better evaluate, treat and communicate withchildren who are overweight, obese or at-risk.

n The Hungry Red Planet. WellPoint has distributedover 2000 CD ROMs of this award-winning computergame to participating physicians for distribution topatients. This game, developed with support from anNIH grant, teaches children important nutrition infor-mation while they attempt to help build a colony onthe Hungry Red Planet. More information is availableat: www.hungryplanet.com

Health Improvement Resources for Adult Members

WellPoint’s disease management programs and preventionand wellness initiatives are developed centrally by the HealthImprovement Resources division and include telephone-based programs for individuals with diabetes, congestiveheart failure, asthma and other chronic conditions. All ofthese programs are available to WellPoint’s fully-insured

GUEST ESSAYS


Combating Obesity Will Require New Models of Care

By William H. Dietz, MD, PhD, Director, Division of Nutrition and Physical Activity,National Center for Chronic Disease Prevention and Health Promotion, Centers for DiseaseControl and Prevention

Our health care system evolved over many decades to address acute medical problems likeinfectious diseases or injuries, and it has not yet adapted to the care of patients with chronicdiseases like diabetes, heart disease and obesity that are the principle causes of death andhuman suffering today.

Perhaps the most important strides in addressing the obesity epidemic over the next decadewill come from the dramatic improvements we must make in caring for people with chronicdisease. We need new and reengineered systems to deliver such care. Such systems will haveto be more effective and efficient.

In many clinical settings, the co-morbidities of obesity — such as diabetes, cardiovasculardisease, or osteoarthritis—are managed in different clinics. The need for integration and sharedinformation is essential. Therefore, one avenue to improve care for obesity will be the electronichealth record (EHR). For example, incorporation of the body mass index (BMI) as a vital signin an EHR could lead to prompts for care linked to the severity of obesity.

We may also have to move away from a physician-centric model of care for some chronic dis-eases, including obesity. Doctors are likely to continue to oversee the care of obese patients.But physicians may not be the most appropriate providers to deliver care on an ongoing basis.Physicians have little time, are expensive, and are poorly trained in behavior change strategies.Care is likely to be delivered more efficiently and effectively by nutritionists, nurse practition-ers, or social workers trained in strategies to change behavior, like motivational interviewing.

The model of care must move toward helping overweight and obese patients develop theskills for self-management of their condition and enable and empower families to managetheir child’s weight.

Environmental changes in schools, worksites, or communities represent another element criti-cal to patient self-management. For example, overweight children and adolescents will notmake more healthful food choices in schools if those choices are not available. Obese adultsmay not be able to initiate a walking program unless their neighborhood has sidewalks or safeareas to walk.

The need for complementary medical and environmental systems to help obese patients man-age their weight offers novel opportunities for alliances between medical and public healthsystems. Some models already exist. Blue Cross Blue Shield of Massachusetts, for example,has partnered with the CDC-funded state nutrition, physical activity and obesity program todevelop the “5-2-1” campaign for public schools. This campaign promotes daily intake offive fruits and vegetables, two hours or less of television viewing, and one hour of physicalactivity. Kaiser Permanente has partnered with the Steps to a Healthier US program in severalcommunities to control obesity, diabetes, and asthma through tobacco control, nutrition, andphysical activity.

GUEST ESSAY 45

We Must Attack Childhood Obesity

By Kenneth R. Melani, MDPresident & CEO, Highmark Inc., Pennsylvania

I belong to a generation of physicians that was trained at a time when domestic disease epi-demics commanded a relatively minor focus. Unlike the physicians who taught us, and who asyoung men and women had worked tirelessly to combat the ravages of polio, smallpox anddiphtheria, we came of age with a more proactive and optimistic view of the contribution wecould make to improve the community’s health.

Because health professionals and the lay public alike continue to define the word “epidemic” inthe context of diseases with well-defined, specific causes and manifestations—polio, for example— we have allowed ourselves to become immersed in a much more insidious type of epidemic —chronic diseases spawned by unhealthy lifestyles. To appreciate the scope of the situation, considerthis: fully half of the two million premature deaths that occur in this country each year resultfrom modifiable behaviors. Moreover, because 70 percent of the burden of illness today is relatedto lifestyle, it is in fact preventable.

Obesity, particularly childhood obesity, contributes significantly to the toll exacted by preventa-ble illnesses. In fact, given that about a third of American kids are overweight, obesity amongchildren and adolescents clearly qualifies as an epidemic.

Both as a physician and as the CEO of one of the nation’s largest health insurance companies, Iam greatly concerned about the downstream ramifications of the epidemic of childhood obesity.Overweight children are at substantially greater risk of developing serious medical problems,including heart disease, diabetes and certain types of cancers.

In addition to the price these children eventually will pay in terms of their health, there also willbe a substantial financial price to be paid—a price the nation simply may not be able to afford.

I believe strongly that we can forestall much of this suffering and cost by dealing with theproblems of childhood obesity in the same way we dealt with earlier epidemics — througheducation, awareness and prevention. It has long been Highmark’s focus to create a healthiercommunity in Pennsylvania. Through developing and sponsoring innovative programs, we arebuilding bridges for health care professionals and community-oriented groups to work together.


Countering Obesity: Our Culture Needs A Shock

By David Katz, MD, MPH, Associate Clinical Professor of Public Health and Director of thePrevention Research Center, Yale University School of Medicine

When pondering the ever-worsening toll of epidemic obesity, it is increasingly common to notethat our genes have changed little in nearly 100,000 years, and are thus woefully out of placein an environment of fast food restaurants, satellite dishes, and DVDs. In large measure, it is theincompatibility of slow moving genes with accelerating environmental change that renders bothNature and Nurture the parents of obesity.

These reflections can be discouraging, because revising the environment is hard to do andreengineering genes even more so, if possible at all. There is thus something hopeful in identi-fying obesity’s “third” parent: cultural inertia. The blistering pace of change — going fromhorseless carriage to Mars rover and from rickets to prevailing caloric overload in the span ofa single century — has left our cultural norms, as well as our genes, in the proverbial dust.

Throughout human history, food has been a fundamental and often rate-limiting influence onsurvival. So naturally almost every culture reveres food as a precious commodity. Of course alavish display, a shared feast, is a time-honored demonstration of friendship, love, hospitality.No wonder food marches through our very lexicon as a measure of prosperity and status: wespeak of “making dough,” being the “bread winner,” and “bringing home the bacon.” No won-der we cringe at waste, encourage plate-cleaning, and revere the “all you can eat” buffet.

These attitudes are anachronisms, cultural imperatives that no longer apply. Consider the falsebargain in saving money by “supersizing” or “chowing down” at all-you-can-eat buffets, thenwriting checks for lotions, potions, or programs to help lose all the excess weight we gainedfor free!

But that is the hopeful element in cultural inertia: at some point, it just gets too silly to over-look. And once we recognize the ridiculous in ourselves, we can change it. Unlike our genes,culture is a medium we can alter and control. Culture is where the danger in the obesity crisismeets opportunity.

As a nation of parents informed of the threat epidemic obesity poses to our children, we canabandon hand-me-down admonitions about “starving children in Europe…” and surrender ourpreoccupations with plate-cleaning. We can, instead, put less food on our children’s plates,and pat them on the back if they have the good sense to stop eating when full.

We can recognize that nutrition and physical activity belong on the short list of things to talkover with our kids, along with sex, drugs, tobacco, and alcohol. And we can recognize thattalking the talk is not enough; we need to walk the walk, literally-setting an example of phys-ical activity, as well as good nutrition, for our children to follow.

We should insist that schools be safe nutritional environments. We can clamor for buildings inwhich stairs are prominent and inviting, elevators, perhaps, less so. We can accept that in themodern age, stuffing food into friends and family is not an act of hospitality and devotion, butthe propagation of a public health threat! Going for a walk could become a holiday tradition.

Culture is our collective pond. Its complacent surface reflects our outdated attitudes back at us.Anyone of us could be the first to shock those images away — just by tossing a pebble.

GUEST ESSAY 47

Health Plans “Positioned to Lead” on Obesity

By Eric J. Berman, DO, MSMedical Director, Horizon Blue Cross Blue Shield, New Jersey

The overwhelming burden that obesity places on the quality of life and the cost of health careis irrefutable. Unchecked, this epidemic will ensure that the life expectancy of our children’sgeneration both fails to surpass that of our own and continues to swell the ranks of uninsuredAmericans for whom health care has become an unaffordable luxury. Health plans have his-torically been reluctant to address health policy concerns that were considered to be within thedomains of government, academia or society at large. They also have been hesitant to investin programs whose potential return on investment could be jeopardized by the migration ofmembers to competitors.

Given the gravity, rapid escalation, and broad impact of obesity, that position must changequickly if we are to have any real hope of reversing this deadly trend. Horizon Blue Cross BlueShield of New Jersey, for one, has recently initiated a multiyear plan to address critical healthissues, including obesity, that adversely effect the health and well being of all residents in ourgeographic region, regardless of whether they are Horizon enrollees.

Many forces contribute to the American obesity epidemic. Economic and cultural driversreinforce behaviors that promote obesity. Our nation’s cultural diversity creates disparitiesin the delivery of care to the overweight and obese members of minority populations.Furthermore, a plethora of “treatments” exist with weak evidence of effectiveness. As aresult, it has been unclear for many years what medical interventions work and how bestphysicians and health plans can help people lose excess pounds and/or maintain a healthybody weight. Most plans therefore have not reimbursed providers for identifying and treatingobesity as the primary diagnosis.

Not surprisingly, patients frequently have failed to receive adequate education on the impor-tant role prevention and lifestyle changes play in reversing the medical consequences of obesity.That too is about to change. The Centers for Medicare and Medicaid Services (CMS) recentlyremoved language suggesting that obesity was not a disease. This shift will effectively allowtreatments with a proven track record to be considered for reimbursement.

Although several factors contribute to the development of obesity, the key to controlling itfrom a public health standpoint lies in uniting public and private sector resources behindthe message that healthy weight is critical to long-term health and that healthier weight cangenerally be achieved and maintained through moderate daily exercise with a well-balanced,portion-controlled diet.

Health plans are well positioned to lead this effort by initiating and sponsoring educationalinitiatives, developing care coordination programs for weight management, and designinginnovative products that create economic incentives for providers to manage, and members tosustain, healthy lifestyle choices. Together with like-minded organizations and governmentagencies, we can and must exchange our national metabolic energy imbalance for an epidemicof health.


The Obesity Epidemic

By Helen DarlingPresident, The National Business Group on Health, Washington, DC

Who would have guessed ten years ago that one of the largest threats to the well-being of our country and the quality and productivity of our workforce would be the huge number ofAmericans who are seriously overweight or obese? A frightening proportion of this group alreadyhas major health problems, such as diabetes and heart disease.

It will be hard to make the kind of dramatic social and behavioral changes needed to reverse thisepidemic anytime soon, especially given the growing number of children, adolescents and youngadults who are already obese. Improvement will be slow in coming and progress may be meas-ured in inches.

But that cannot be an excuse for inaction. Indeed, it means we must redouble our efforts.America’s employers and companies increasingly recognize the challenge. They are motivated inno small measure by the threat of being swamped financially by the costs (estimated at $117 bil-lion in 2003) of obesity and its impact on health and productivity. In addition, they understandthat obesity and serious overweight have a tragic effect on the quality of life and safety of theiremployees and family members.

In 2003, the National Business Group on Health concluded obesity was in fact the most urgenthealth crisis facing American business and its workers. We also concluded that we had to move asfast as possible to develop a strategy, related tactics and solutions that employers could useimmediately. We founded an Institute on the Costs and Health Effects of Obesity.

The Institute’s major goals are to identify the most effective programs and best practices to pro-mote healthy weight and healthy lifestyles —and then to disseminate this knowledge, with specificrecommendations, in a proactive manner. We have already begun to urge employers to do the following:

n Encourage health plans to develop effective healthy weight and weight reduction programs

n Select health plans that help physicians make weight reduction and management a high prior-ity in all patient encounters

n Develop a comprehensive, corporate-wide health improvement program and food policy (e.g.,eliminate mindless unhealthy snacking at meetings)

n Contract with food and snack service vendors to increase healthy options and label all food

n Offer on-site or near-site programs, such as Weight Watchers at Work

n Create safe, attractive opportunities to walk, use stairs, and get moving

n Subsidize the use of health risk appraisals, risk status personal counselors, and other tools tomotivate healthy weight

n Work with federal agencies to evaluate weight management programs. Medicare will have tofund studies that demonstrate what programs or treatments will be effective in helping themillions of obese Medicare beneficiaries (18%) lose weight and become more active.Otherwise, Medicare will be bankrupt by paying for the terrible consequences of obesityamong disabled and elderly beneficiaries.

Obesity is preventable. We must implement programs aimed at helping overweight employees andtheir dependents lose those pounds, increase activity, become healthier and enjoy a higher qualityof life. Employers have no choice. Corporate America must act in their own best interest to tacklethis issue, but that interest is in every way also the interest of their employees and communities.

GUEST ESSAY 49

Obesity: Integrated Medical-Public HealthApproach Needed

By George Isham, MD, Medical Director and Chief Health Officer, HealthPartners, Minnesota

The health plan community in the U.S. must become a leader in the social and cultural struggle nowunderway to prevent and manage obesity and overweight. There is simply no more important problemaffecting the health of our enrollees and the broader U.S. population right now. We need to begin tobuild programs and a benefit structure that supports healthy living and eating and results in reducingbehavioral risk factors.

Collaboration between the private and public health sectors is essential in this effort. CDC and otherpublic health agencies must exhibit clear leadership in laying out an evidence-based overall strategy.That process is underway, and it needs full support for effective implementation and dissemination.Health plans will then be in a position to actively deploy those public policy and public healthapproaches for their members. Both sectors must also join forces to foster and support community-based initiatives and organizations that will help people be active and live healthier lives.

Together with the public sector, we then need to conduct rigorous evaluations of medical, surgicaland behavioral interventions for obesity, including counseling and weight loss programs. We mustask the hard questions about what really works, and we must generate hard evidence. Evaluatingthe cost-benefit ratio has to be a part of that process.

Most interventions that are covered under insurance are now at the end of the obesity spectrum —that is, surgical interventions for the morbidly obese. Some plans also cover some drugs known tobe safe and effective. But for the most part behavioral interventions and counseling are not coveredservices. To have an meaningful impact on obesity in our populations, health plans should be preparedto extend coverage to medical, behavioral and counseling interventions that are proven effectiveand safe. Health plans should deploy these evidence-based interventions for the overweight as wellas the obese and morbidly obese.

Implementing new coverage for non-surgical approaches will require mechanisms to ensure that non-evidence based and ineffective approaches are not encouraged. In an environment with a plethora ofproducts and services for the overweight and obese that are ineffective or in some cases quackery, thiswill be a challenge.

The reason is cost. Cost pressures in health care are powerful and growing. While obesity is costingus billions, neither employers nor health plans are in a position to broadly expand this area oftreatment without solid proof of a long term return on the investment. In Minnesota, for example,if 50% of our 600,000 or so enrollees are overweight or obese, as is the case, and all might beeligible for intensive behavioral therapy or dietary approaches, that would be a tremendousincrease in costs on an already strained system.

There are some things we ought to do right away. One is to promote the measurement of Body MassIndex (BMI) as a vital sign. Another is to begin to help physicians to feel more competent in advisingpatients on weight loss, eating and activity. We know that many doctors are quite frustrated trying toprovide this help. And we know they see it as one more thing they have to do in the 10 minutes or sothey spend with a patient.

A third action is to tighten the criteria for bariatric surgery and to expand the screening of candi-dates. This is a complex and invasive procedure that has a huge physical and physiological impactand a sizable potential for complications. Not everyone benefits.

Many people have begun to draw analogies between preventing obesity and smoking cessation.Clearly, both are broad public health problems that require an integrated medical and public healthapproach. I’m certain there are lessons as we attempt to promote changes in people’s behavior toreduce overweight. But obesity also has its own unique set of issues. The sooner we begin to definethose issues and start effectively helping people achieve a healthy body weight, the better.


The Physician’s Dilemma

By Robert F. Kushner, MDMedical Director, The Wellness Institute, Northwestern Memorial Hospital, Chicago, ILEditor, The American Medical Association’s Brochure Series on Obesity Management

Today’s physician is faced with an enormous dilemma. Statistically, two out of three adult patientsand nearly two out of every ten children are overweight or obese and at risk for developingmultiple chronic diseases that will need life long treatment. Although physicians are trained totreat the consequences of obesity — diabetes, high blood pressure, and elevated blood lipid levels,among others — they are woefully unprepared to treat or prevent the underlying causes.

Medicine, including its system of delivery and reimbursement structure, is geared toward address-ing acute care problems that can be tended to in single ten minute office visits with provision ofa prescription. Unfortunately, this structure is inconsistent with the delivery of care needed for thetreatment of overweight and obesity. Herein lies the dilemma of healthcare for the most preventa-ble cause of death over the coming decades.

At a time when government agencies, national medical organizations, and the media are increasinglyfocusing their attention on obesity, physicians and insurers have responded with — so far —unproductive answers. Whether due to lack of training, confidence, interest, time or knowledge,physicians do not often view their patients’ obesity as a medical problem that they need toaddress. The prevailing view, sadly, is that it’s the patients’ fault or responsibility that they aregaining weight and therefore, the patient needs to take responsibility and do something about it.

Even though the recently released U.S. Preventive Services Task Force recommended that cliniciansscreen all adult patients for obesity and offer intensive counseling and behavioral interventions topromote sustained weight loss for obese adults, it is difficult to appreciate how this recommenda-tion will be implemented given current attitudes, practice behaviors and time constraints amongprimary care physicians.

For the insurers’ part, obesity still remains an ‘excluded benefit’ for many patients, forcing indi-viduals to pay out of pocket for treatments and solutions that are guided by fad diets, commercialprograms and internet support groups. If a physician chose to become involved in the patient’sobesity care, the insurance company would not likely cover the visits and the anti-obesity medicationprescribed. One of the most frustrating barriers for some patients is obtaining coverage forbariatric surgery. Due to an avalanche of surgical requests, many insurance companies are eitherdenying coverage entirely or putting up roadblocks in the approval process.

There are no easy solutions. Physicians must become engaged in the delivery of obesity care andinsurers must provide better benefits. This will require creative changes for both groups. A recentlyreleased Primer for Physicians on the Assessment and Management of Adult Obesity by theAmerican Medical Association (www.ama-assn.org/ama/pub/category/10931.html) is a step forward.It provides physicians with the strategies, skills and tools needed to offer obesity care. For theirpart, insurers and health plans need to partner with employers, patients and physicians to developincentives to prevent and treat obesity. Working together, physicians and insures must build thecare systems needed to promote integrative services for obese individuals, incorporating dietitians,health psychologists and exercise specialists. Nothing short of a team approach will meet thechallenges this population presents.

Many people have begun to draw analogies between preventing obesity and smoking cessation.Clearly, both are broad public health problems that require an integrated medical and public healthapproach. I’m certain there are lessons as we attempt to promote changes in people’s behavior toreduce overweight. But obesity also has its own unique set of issues. The sooner we begin to definethose issues and start effectively helping people achieve a healthy body weight, the better.

REFERENCES1 Prevalence of Overweight and Obesity Among Adults: United States,

1999-2002. National Center for Health Statistics, Centers for DiseaseControl and Prevention. Available at www.cdc.gov/nchs/products/pubs/pubd/hestats/obese/obse99.htm

2 Ibid.

3 Epstein LH, Wing RR, Valoski A. Childhood obesity. Pediatric Clinics ofNorth America Am 1985;32:363-79. Malina RM. Ethnic variation in theprevalence of obesity in North American children and youth. CriticalReviews in Food Science and Nutrition 1993;33:389-96.

4 Sturm R. The Effects of obesity, smoking and drinking on medical prob-lems and costs. Health Affairs. 2002 Mar-Apr; 21(2):245-53.

5 Mokdad et al. Prevalence of Obesity, Diabetes, and Obesity-Related HealthRisk Factors, 2001. Journal of the American Medical Association2003;289:76-79.

6 Thompson D et al. Body Mass Index and Future Healthcare Costs: ARetrospective Cohort Study. Obesity Research. 9(3):210-218.

7 CDC’s role in promoting healthy lifestyles. Testimony of Julie Gerberding,MD, MPH, Director of the Centers for Disease Control, before theCommittee on Appropriations, Subcommittee on Labor, HHS and RelatedAgencies. February 17, 2003.

8 Finkelstein et al. National Medical Spending Attributable to Overweightand Obesity: How Much, and Who’s Paying? Health Affairs, May 2003.

9 Thorpe et al. Trends The Impact of Obesity on Rising Medical Spending.Health Affairs Web Exclusive W4-481, October 2004.

10 O’Brien et al. Identification, Evaluation, and Management of Obesity inan Academic Primary Care Center. Pediatrics 114(2):e154-e159

11 Brownell, K. Obesity and Managed Care: A Role for Activism andAdvocacy? June 2004 American Journal of Managed Care, pp. 353-354

12 The Clinical and Community Guides: Spanning the Boundaries BetweenClinics and Communities to Address Overweight and Obesity. Dr. PeterBriss presentation for America’s Health Insurance Plans conference callon Reversing the Trends in Obesity and Health Related Conditions,February 24, 2004.

13 The State of Preventive Health: A Report from Blue Cross and Blue Shieldof North Carolina, September 2004.

14 Friedland R. Understanding health literacy: new estimates of the costs ofinadequate health literacy. Presented at the 3rd Annual Conference onHealth Literacy. 1998.

15 Health Literacy: A Prescription to End Confusion. Institute of Medicine.April 2004

16 The Stages of Change Model (SCM) was originally developed in the late1970ís and early 1980ís by James Prochaska and Carlo DiClemente at theUniversity of Rhode Island when they were studying how smokers wereable to give up their habits. The SCM model has been applied to a broadrange of behaviors including weight loss, injury prevention, overcomingalcohol, and drug problems among others.

17 Thompson D, Edelsberg J, Kinsey KL, Oster G. Estimated economic costsof obesity to U.S. business. American Journal of Health Promotion.1998Nov/Dec; 13(2):120-127

About the NIHCM Foundation

The National Institute for Health Care Management Foundationis a non-profit organization whose mission is to promoteimprovement in health care access, management and quality.

About This Report

This publication was supported by cooperative agreementNumber US5/CCU387112-05 from the Centers for DiseaseControl and Prevention (CDC). Additional support for the publication was provided by the Health Resources and ServicesAdministration's Maternal and Child Health Bureau (MCHB)under cooperative agreement No.5 U93 MC 00143-07. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of CDC and MCHB.

This NIHCM Foundation Report was prepared under the direc-tion of Nancy Chockley by Jason Lee ( [email protected]) andAdele Shartzer ([email protected]), with the assistance ofGaylee Morgan, Matt Powers, and Tracy Tang at HealthManagement Associates. We would like to thank the healthplans for participating in the development of this report, theseven guest essayists for their contributions, and Steve Findlayfor initiating this project. We would also like to thank LisaKoonin for her helpful comments and guidance.

National Institute for Health Care Management Foundation1225 19th Street, NW, Suite 710Washington, DC 20036202.296.4426202.296.4319 (fax)www.nihcm.org

health plans emerging as pragmatic partners in fight ... · figure 5. trend in bariatric surgery...

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