Obesity now affects more than one in five children in the United States. Although effective and recommended treatments exist, access to them is limited for most children. In two new studies, researchers at Yale University examined the cost-effectiveness of one treatment and factors that have hindered or facilitated implementation of another, enabling them to develop strategies to improve access to effective treatments for childhood obesity.
The publications come at a timely pace, as Yale experts serving as members of national medical organizations have endorsed a proposal under review by the Centers for Medicare and Medicaid Services for a new billing code that could allow facilities to be reimbursed by health insurers for intensive behavioral health and lifestyle treatment interventions for childhood obesity. Such a change would encourage implementation of these programs and improve access to them, the researchers say.
The studies were published August 28 in the journal Obesity.
Previous studies have shown that interventions that include comprehensive, family-centered nutrition and behavioral education and at least 26 hours of contact with families over a 3- to 12-month period are effective in treating childhood obesity. These types of programs have been recommended by both the U.S. Preventative Service Task Force and the American Academy of Pediatrics.
““We have treatment options that work,” said Mona Sharifi, author of both studies and an associate professor of pediatrics at Yale School of Medicine. “But we have these systematic barriers to access that we need to address quickly.”
Costs are a constant concern in health programs, including obesity treatment. In the first new study, Sharifi and her colleagues examined the costs – from both a medical and societal perspective – associated with implementing the Healthy Weight Clinic intervention in federally qualified health centers.
The Healthy Weight Clinic is a program that provides intensive behavioral and lifestyle health treatment to children and adolescents who are obese or overweight, consistent with American Academy of Pediatrics guidelines. The treatment model brings together teams of pediatricians, dietitians, and community health workers in primary care settings where families are likely already involved.
For the first new study, researchers specifically examined federally qualified health centers because they offer their services in underserved communities.
“This was done intentionally to gain access to communities disproportionately affected by obesity disparities,” Sharifi said.
In their analysis, the researchers broke the intervention down into its smallest components – staff, materials, etc. – and determined their costs. They also estimated the costs families incur in the form of time, transportation, and child care costs associated with participating in a Healthy Weight Clinic. They then entered these costs into a model that simulated a sample of patients over a 10-year period, some of whom participated in a Healthy Weight Clinic intervention.
“We were able to extrapolate those calculations and ask ourselves, “If we could expand this intervention to all federally qualified health centers in the United States, what would the situation look like in 10 years?” Sharifi said. “How many cases of obesity could we prevent? How much would it cost, and how much could we save by improving the health of the children reached by the intervention?”
They concluded that if Healthy Weight Clinics were established in all federally qualified health centers within ten years, the intervention could reach 888,000 children with obesity or overweight and prevent 12,100 cases of obesity and 7,080 cases of severe obesity.
The cost was estimated at $667 per child, of which $456 was borne by the health sector and $211 by families. At the same time, the reduction in obesity cases would save approximately $14.6 million in health costs.
““It is a relatively inexpensive intervention that our study team has already found to be effective,” Sharifi said. “And given the populations served by federally qualified health centers, our findings also suggest that scaling up this intervention could mitigate health disparities among underserved populations.”
In the second study, researchers investigated another intervention by examining the dissemination of a curriculum called Smart Moves, which evolved from a program developed at Yale called Bright Bodies. Previous research by Sharifi, Mary Savoye (the founder of Smart Moves), and their colleagues has shown that Bright Bodies is both effective in improving health outcomes in children with obesity and overweight and in saving costs compared to usual clinical care.
From 2003 to 2018, the SmartMoves program was implemented in over 30 locations across the United States. The new study collected experiences from employees who worked at those locations to find out what factors facilitated the implementation of the program and what obstacles stood in the way of its success.
Key enablers of SmartMoves implementation included local partnerships with schools and sports facilities, which helped provide resources and generate demand for programs from families.
The biggest obstacle to sustainability was uncertainty about financing, which often led to failure of efforts to implement or sustain new programs.
“If a child breaks their arm, the family seeks help and the clinic or hospital bills the insurance company for the treatment. This funding model doesn’t work as well for treatment programs aimed at improving health behaviors and lifestyle,” Sharifi said. “Bright Bodies, for example, includes group visits with families and is led by a nutritionist, an exercise physiologist and a social worker. So you typically don’t get reimbursement from insurance companies, even though Bright Bodies appears to be more effective and less expensive compared to usual clinical care. These programs often rely on grants, but these are running out and the programs disappear, leaving communities without access to standard treatments.”
To enable reimbursement for effective programs such as Bright Bodies and Healthy Weight Clinic, several organizations, including the American Academy of Pediatrics, the American Academy of Family Physicians, and the U.S. Centers for Disease Control and Prevention, have submitted a proposal to implement a new billing code. The proposal will be considered by the Centers for Medicare and Medicaid Services over the next few months.
“If the bill is approved, I think it would open the door to funding the most efficient and appropriate type of treatment and giving families more options for interventions,” Sharifi said. “Something like this – treatments that are standard of care and not reimbursed – would never happen in a field like surgery. But it does happen in pediatrics because children are often neglected in U.S. health care policy and pediatricians often get short shrift when it comes to billing.”
She believes a policy change is needed to ensure that this first-line treatment is accessible to families across the country.
““There is an urgent need to expand access,” Sharifi said. “And it is unethical not to give children equal access to effective and affordable treatment.”
