Obesity Report

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 Panels 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 nationsprominent 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 nations 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 nations 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 nations 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 360Health 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 states 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 Caf Program, Be Active North Carolina, Inc.,and Fit Together. Horizons 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 publics 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 paida 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 HospitalsWellness Institute writes in his essay that physicians arewoefully 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 ofHorizons 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 theemployers worksite to make it easier for members toparticipate. Dataor rather the lack thereofwas 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 parksbudgets. 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. KPsgoal 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 Universitys 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 Permanentes 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 members 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 Healths 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

Aetnas 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 members 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 patients 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 programs 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 Plana 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 thePCPs 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-bers 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, forAffinitys non-Medicaid membership. Drugs are carvedout" of New Yorks 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 nationslargest 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 Medicarereasonable 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! CliniciansToolkit 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 BCBSMAs 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 childrens 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 BCBSMAsnetwork 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 studys 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 theprograms messages. In addition, BCBSMA has committedto establish a permanent Jump Up and Go! exhibit at theChildrens 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". Thistoolbox" 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 foundationsfour 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 KidsCaf 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-pants 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 ShieldsWalking 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 ofEmpires 360 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 enrollees 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 members 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 p

Obesity Report

Documents

obesity epidemic

prevalence of obesity

large health plans

empire blue cross blue

horizon blue cross blue

physical cause of obesity

emerging role of health

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