Roberta Clarke

What’s the return on fighting obesity?

By Roberta Clarke
September 24, 2009

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WHILE RECOGNITION of childhood obesity is widespread, solutions to the problem are in surprisingly short supply. Having just closed one of the few pediatric obesity treatment programs in New England, I can identify one of the most cogent reasons for the shortage of such programs: ROI, or the return on investment demanded by health insurers.

Our program, Great Moves, was co-founded with health care entrepreneur Stanley Goldstein in collaboration with Children’s Hospital.Families met once a week for five months. The kitchen in the center taught families how to cook. A gym attracted the children with Wii Fit, a version of Dance Dance Revolution, and a Sport Wall. Behavioral counseling was provided as were lessons on such issues as portion size, environmental cues that trigger inappropriate eating, and distinguishing between eating due to hunger vs. boredom.

Most important to the success of the program was retention - that is, keeping the parents and children actively attending the program weekly for five months. It took a long time for the children to become heavy and it was expected to take an equally long time to change family behavior. The program anticipated that parents would pay out-of-pocket monthly and be reimbursed at the end of the program for roughly one-third of the cost if the children met certain health, attendance, and weight-related goals. It was expected that insurance companies would be willing to remit this cost to their participating families due to the long-term savings of not having to treat obesity-related illnesses.

Initial meetings 18 months earlier with the insurance companies had suggested that, if the program worked - that is, for example, if the children’s body mass index numbers started to stabilize or fall rather than rise - insurers would discuss paying part of the program cost. When our first set of children completed the program in the spring, the results were not celebratory but adequate, with 70 percent of the children achieving this modest goal.

Insurers responded by saying they would not pay for the program, not because the program did not work but because it did not meet their 12-month return-on-investment goal. With families changing their insurance plans on average every three years, the insurers reasoned that by the time one of the Great Moves children avoided diabetes or other obesity-related health problems due to the program intervention, that child would no longer be covered by that insurer. Therefore, the insurer would lose its investment in making that child less obese.

While this may sound like a heartless assessment, it is understandable that they weigh the health of their members against their corporate financial interests. If short-term financial performance dictates the health insurers’ decisions about programs and procedures in their benefit structure, then insurers will cover only modest, less costly programs intended to address long-term problems such as pediatric or adult obesity.

This explains why so few programs exist to treat obese children: Sustainable funding for well-designed long-term pediatric obesity programs is nearly nonexistent. Insurers’ limited grants to foundations to support community action against pediatric obesity or their participation in initiatives such as President Clinton’s Alliance for a Healthier Generation do not constitute coverage, but rather goodwill and good public relations. Further, insurer payments to pediatricians to address obesity in their patients are both insufficient and to date largely ineffective.

The question then remains: Who will be responsible for addressing - and paying for - the pediatric obesity epidemic?

The changes being proposed to the US health care system should encompass long-term return on investment, meaning financial incentives for insurers to address longer-term health problems. Otherwise, the current short-term focus assures that the US health care system will be carrying this heavy burden of pediatric obesity well into the future.

Roberta Clarke is an associate professor in the Health Sector Management Program at Boston University and vice chair of the boards of the New England Organ Bank and the Academy for Educational Development.

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