By HANNAH MARTIN MPH, RD; JENNY BOGARD; WILLIAM DIETZ, MD; ANNE VALIK; NICHOLE JANNAH; CHRISTINE GALLAGHER; ANAND PAREKH, MD, MPH; DON BRADLEY MD
The United States has been facing a mounting obesity epidemic for over a generation, but our health care system has struggled to keep up. Given the complexity of obesity and the pace of curricular change, obesity education for our health-provider workforce is still lacking. There are wide disparities in quantity and quality among programs and disciplines. Similarly, public and private payers have taken vastly different approaches towards coverage for obesity treatment and prevention, which even leaves the most educated providers unsure of what services each patient can access. Because coverage decisions are based partly on what providers are prepared to provide and curricula are based partly on what services are typically covered, these problems reinforce one another. Despite these challenges, several important steps have been taken recently to tackle both sides of the problem. The steps include the development of new Provider Competencies for the Prevention and Management of Obesity and the launch of the My Healthy Weight pledge to standardize coverage for obesity counseling services.
Why We Must Act
In the US, more than one-third of the adult population and nearly one-fifth of the children have obesity. Adult obesity prevalence is projected to reach nearly 50 percent by 2030. Adult diabetes prevalence currently hovers around ten percent and is further projected to affect one-third of the adult population by 2050. Estimates for the total annual medical cost of obesity in the U.S. range from $147 billion to $210 billion, with billions more lost in productivity due to absenteeism and presenteeism. Obesity is also a national security issue. As of 2010, 27 percent of young adults were disqualified for military service due to obesity.
Improving Obesity Education for Health Care Providers
Despite these shocking rates of obesity, fewer than one in four physicians feel that they received adequate training in counseling patients on diet or physical activity. Obesity concepts are underrepresented on medical licensing examinations and substantial gaps in provider knowledge related to obesity care have been recently documented. This is not surprising considering that less than 30 percent of medical schools meet the minimum recommended number of nutrition-related content hours.
The decision to develop interprofessional obesity competencies grew out of two related activities. A 2013 convening and 2014 white paper that we organized and authored on training doctors for prevention-oriented care, established that a major barrier to improving the knowledge base was a lack of clarity on what exactly should be taught. At the same time, a publication by several members from an Innovation Collaborative associated with the National Academy of Sciences, Engineering, and Medicine’s Roundtable on Obesity Solutions pointed to the need for integrated approaches to obesity prevention and management.
These led to the formation of a working group consisting of 24 diverse organizations representing a dozen health professions involved in the care of people with obesity. Over the course of 18 months, the working group developed 10 core competencies for obesity education that include demonstrating knowledge of obesity as a disease and its epidemiology, recognition of bias and stigmatization, interprofessional collaboration, and the need for patient-centered communication and physical accommodations.
To promote the integration of the obesity competencies into training programs, we launched an Innovation Award for Health Care Provider Training and Education to recognize health professional training programs that provide innovative nutrition, physical activity, and obesity counseling education and have incorporated one or more obesity competencies into their curricula. Now in its second year, the Innovation Award recognizes the leadership of inventive educational models from all health disciplines and serves to inspire others with examples of what can be achieved.
Improving Reimbursement for Obesity Services
Payments to providers for counseling in nutrition, physical activity, and behavioral health for obesity are another major barrier to the prevention and management of obesity. Although some health insurers have increased coverage for preventive care services, adequate reimbursement for obesity care is rarely a top priority. A survey of Medicaid coverage of obesity services shows that coverage is highly variable and often deficient across states.
To address the lack of coverage and standardization with the insurance marketplace, we convened over 20 private insurers, large self-insured employers, and state Medicaid agencies to devise a standardized benefit obesity counseling services. These forward-leaning payers collaborated for over a year to develop the My Healthy Weight pledge, which launched in November 2017 and now boasts 11 signatories who collectively cover over 10.5 million lives. Key components of the pledge include covering intensive behavioral interventions and evidenced-based community programs for both adults and children with specified risk factors. While these benefits are currently structured for a fee-for-service payment model, we hope to move towards quality-based payment models for obesity in the future.
Looking to the Future
Moving the needle on the obesity epidemic will require all schools and programs that train health professionals to integrate obesity education into their curricula. To facilitate this effort, we have created a database of curricular resources for educators and will continue to recognize exemplary training programs annually through the Innovation Award. We will also identify and address profession-specific gaps in provider education and training on obesity prevention and management.
To capitalize on the momentum of the founding members of My Healthy Weight and support their continued leadership in this process, we will provide ongoing technical assistance and resources as our first cohort of signatories works to implement the benefit for the plan year 2019. We are also working with additional payers to sign the pledge for the plan year 2020.
The costs of obesity emphasize the need for revising care delivery and the importance of clinical-community partnerships to effectively mitigate the obesity epidemic. These improvements cannot come overnight and will require that educators, students, health care providers, health systems, payers, employers, and governments make obesity prevention and care a high priority.
Hannah Martin, MPH, RD, Senior Policy Analyst, Bipartisan Policy Center
Jenny Bogard, MPH, Founder and Managing Partner, Commonality
William Dietz, MD, Ph.D., Director of Sumner M. Redstone Global Center for Prevention and Wellness, George Washington University
Anne Valik, MPH, Founder and Managing Partner, Commonality
Nichole Jannah, Research Assistant, STOP Obesity Alliance, Redstone Center, George Washington University
Christine Gallagher, MPA, Research Project Director, STOP Obesity Alliance, Redstone Center, George Washington University
Anand Parekh, MD, MPH, Chief Medical Advisor, Bipartisan Policy Center
Don Bradley, MD, MHS-CL, Associate Consulting Professor, Duke University School of Medicine