How self-insured employers can meet ACA nutritional counseling requirement
The American population is getting heavier. From the 1960s to the present, obesity has almost tripled. In fact, experts predict that if current trends continue unchanged, by 2030 more than half of the U.S. adult population will be obese, according to research published in the medical journal The Lancet. These same experts expect skyrocketing obesity to be accompanied by an increase in diabetes and its related comorbidities. The obesity trend can only lead to poorer health for the U.S. population and higher costs for the healthcare industry.
It comes as no surprise, therefore, that the federal government is taking steps to nip obesity in the bud. An update to the Affordable Care Act requires health plans to cover a new preventive service as of this January: Regular nutritional counseling for millions of overweight Americans with other health risks. Specifically, a recommendation by the U.S. Preventive Services Task Force, which the ACA mandates must be adopted by private health insurers, requires them to provide no-cost coverage of nutrition counseling for Americans who are overweight and have at least one cardiovascular risk factor. According to statistics from the U.S. Center for Disease Control and Prevention, 50% of American adults fall into this risk category and so will need to see a dietitian, with self-insured employers picking up the tab.
Nutritional counseling — typically in the form of a referral to a registered dietitian—isn’t cheap. An initial consultation with a registered dietitian costs about $100 to $200, and follow-up visits range from $50 to $150. Multiply these prices by the growing number of overweight and at-risk Americans, and self-insured employers could face a considerable cost increase.
However, employers need not simply brace themselves for an avalanche of new costs. Since few guidelines exist on how to meet this new ACA mandate, employers have the option to deploy unique, cutting-edge approaches to engage members in nutrition services. Proactively embracing innovative nutritional strategies will allow employers to address the mandate — and lower their healthcare spend by reducing the number of people with chronic disease.
The ACA mandates that at-risk individuals receive nutrition counseling support with no out-of-pocket cost. According to the legislation: “A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost-sharing requirements for (1) evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the USPSTF.”
Obviously, this government-speak needs a little bit of explanation. First, the USPSTF. The USPSTF is comprised of experts in prevention, evidence-based medicine and primary care. Their main function is to improve the health of all Americans by advising the provider community on specific services that can help prevent disease. The task force accomplishes this by reviewing research evidence, weighing the benefits and harms of each service, and establishing a rating of A, B, C or D for the service. The lists range from the strongest recommendations to the weakest. List A services are those with the strongest evidence of benefit for Americans. List D are services with no evidence of benefit or that could potentially cause harm. Once a rating is issued, the provider and payer communities can determine how best to administer the service.
In the case of the ACA requirement, self-insured employers must cover USPSTF-recommended preventive services that have an “A” or “B” rating without copays, deductibles or coinsurance, since the experts have determined there is significant benefit for employees for using these preventive services. There are two nutrition-related recommendations that meet this criterion. First is the screening and management of obesity in adults:
1. The USPSTF recommends screening all adults for obesity. Clinicians should offer or refer patients with a body mass index (BMI) of 30 kg/m2 or higher to intensive, multicomponent behavioral interventions.
Second is behavioral counseling for heart disease prevention in adults with risk factors for heart disease:
2. The USPSTF recommends offering or referring adults who are overweight or obese and have additional cardiovascular disease (CVD) risk factors to intensive behavioral counseling interventions to promote a healthful diet and physical activity for CVD prevention.
Both of these recommendations encourage the use of “intensive behavioral therapy” (IBT) as a prevention strategy for individuals with risk factors. Importantly, although the new regulation supports a nutrition-based approach to improving health, it does not dictate exactly what form IBT must take. The USPSTF researched numerous programs with differing durations and modes of delivery (phone, Internet, face-to-face) and found that generally they produced successful outcomes for the two risk groups described above. This is where self-insured employers have the opportunity to innovate.
An unsustainable model
The current model for nutrition services is to offer health plan members who are eligible for nutrition counseling a referral to a registered dietitian or otherwise qualified health professional. Every employee or member who qualifies is directed to a live provider, and every employee receives costly in-person treatment.
Clearly, with the ACA expansion, this model is unsustainable, as health plans and employers will be required to cover the cost of nutrition counseling for millions of individuals. The current model for nutrition referrals also lacks a system for measuring quality or impact, which results in individuals not obtaining the care they need to avert disease. Over time, this can result in higher costs due to the necessity for more medication or treatment to manage complications associated with chronic disease.
While approaches to meet the ACA requirement are at the discretion of each employer or payer, one option is to strategically use the dollars for this benefit by directing people to solutions that have evidence of effectiveness. In other words, investing in intensive behavioral therapies that redirect at-risk individuals down a healthier path can be a wiser use of funds than spending money to simply “check the box” on the mandate.
One such approach involves personalized digital nutrition solutions. These technology-based solutions offer a lower-cost and more effective alternative to traditional interventions. Designed to help employees get and stay healthy, digital nutrition solutions change the paradigm for nutrition services to provide more value for a health plan and better outcomes for patients.
Unlike the traditional approach of referring each qualifying employee to a dietitian, this new paradigm introduces digital therapeutic tools as first-line therapy for individuals qualifying for nutrition counseling. Then, only those employees at highest risk are escalated to the service offered by live providers. Moreover, digital tools, delivered consistently across the employee population, enable a health plan to track the effectiveness of the nutrition intervention. Thus, this innovative approach to nutrition counseling both measures outcomes and fulfills ACA requirements in a cost-effective manner.
"Employers must bear in mind, however, that simply implementing a dietary app might not put them on the road to improving employee health."
Employers must bear in mind, however, that simply implementing a dietary app might not put them on the road to improving employee health. The recent avalanche of digital tracking apps and diets has made little difference to date. In one study, only 17% of people were able to maintain a 10% weight loss for over a year.
There are two potential reasons for this lack of effectiveness. First, evidence suggests that a focus on weight loss itself can prove counterproductive. Studies indicate that a focus on weight loss can induce short-term change but rarely leads to long-term success and health improvement. Instead, researchers recommend a shift in emphasis from weight-management to health-improvement strategies. Second, dietary solutions (even technology-driven ones) have typically offered esoteric food systems and stringent, constant sets of diet recommendations that are disconnected from people’s daily habits.
Today’s personalized digital nutrition solutions overcome these roadblocks. Their focus is simply to make it easier for participants to eat well. This means addressing each individual’s complex relationship with food, integrating across the multiple food touchpoints that the individual is exposed to every day. They deploy more refined technology to improve behavioral economics — addressing food purchasing habits, consumption, availability and price sensitivity as well as demographic, geographic and socioeconomic factors. They promote personalization to create long-term engagement, behavior change and lasting changes in health outcomes.
For example, these solutions create dynamic recipe recommendations based on each employee’s food preferences, allergies and health status. They take into account a user’s food preferences and determine a gradual shift in menu and recipes by replacing unhealthy foods or ingredients with healthier foods a little at a time. They create grocery lists with ingredients from recommended recipes that help employees find affordable, individualized options at local grocery stores. They account for takeout options for any given lunch or dinner. And they take personalization a step further by enabling participants to enter their clinical metrics, such as weight, blood pressure and blood glucose.
These features combine to deliver a behavioral therapy approach that satisfies ACA requirements for the majority of qualified employees. In fact, by empowering employees with personalized, actionable recommendations that foster healthier eating decisions, self-insured employers can engage their populations on the road to better health while avoiding most of the cost of nutrition services. The ACA continues to change the landscape of how health risks can be managed. With the latest ACA expansion, the ball is in the court of self-insured employers to innovate and make the most of this opportunity.