AHIP Coverage (July/August 2008)
Creating the Conditions for Health
Some factors that play a major role in a population’s health transcend the system itself.
By Harris Meyer
UnitedHealth Group is funding an initiative to better prepare low-income children for kindergarten. Anthem Blue Cross has guided schools in protecting asthma-prone children from bad air pollution conditions. Blue Cross & Blue Shield of North Carolina and Kaiser Permanente are helping communities become more walkable and their people less obese.
A new $5 million project by the Robert Wood Johnson Foundation, called the Commission to Build a Healthier America, is focused on analyzing and making policy recommendations about factors outside “health care” that affect how long and how well Americans live. The commission will study efforts outside the traditionally defined health care system to improve the health of Americans.
Meanwhile, a similar commission established by the World Health Organization will issue a report this fall recommending policies for improving the health of the world’s most vulnerable people. It’s expected to have relevance to this country.
There is a growing sense of urgency to the mission of these panels.
New studies by Harvard University researchers published in April found a widening life expectancy gap between richer and poorer Americans and between those with more and less education. Life expectancy actually declined in hundreds of U.S. counties.
Next year, the bipartisan RWJ commission is scheduled to issue a report recommending effective models to improve health through educational, environmental, housing, income-based, and other types of programs. The commission leaders say they hope their panel’s recommendations will be considered as part of any proposed health care reform package.
Commission co-chair Mark B. McClellan, M.D., former Food and Drug Administration commissioner under President George W. Bush, says there’s “widespread recognition that nonmedical factors have a big impact on the health of the entire population, particularly low-income people.” The commission’s task, he says, is to identify the most promising approaches and move them forward on the public agenda.
The panel’s recommendations will flow from regional field hearings around the country, which started in North Carolina in June, and from the study of both public and private programs.
Commission leaders say they will evaluate programs related to early childhood education, nutrition, and increasing daily physical activity but won’t rule out any type of program at this point.
The RWJ project kicked off its initiative with a package of studies published in the March/April issue of Health Affairs looking at demographic-related health disparities between Americans and differences in hospital and physician care.
One of the reports noted that poor, less educated, and minority Americans on average die up to six years earlier than their wealthier, better educated countrymen, and that even middle-class Americans on average die up to two years earlier than more affluent Americans. The lowest-income children are seven times as likely to be in fair or poor health compared with the highest-income children. Racial and ethnic disparities in children’s health exist that are linked to differences in access to “opportunity neighborhoods.”
Commission co-chair Alice M. Rivlin, deputy director of the Office of Management and Budget under President Clinton, says, “A lot of aspects of American life aren’t very healthful, including how we eat and exercise, substance abuse, unsafe neighborhoods, and living far from grocery stores. We are trying to figure out, are there some policies that we could advocate that will help make Americans healthier?” “There is a growing awareness that there is much more to good health than health care alone,” says Karen Ignagni, president and CEO of AHIP . “It’s vitally important, of course, to have insurance and access to medical care. But researchers and policymakers are increasingly pointing to other variables—such as pollution, education, access to good nutrition, the state of neighborhoods, and opportunities to exercise—that can have a profound impact on individual health status.”
Already, many health plans and health providers have recognized the key role of factors such as nutrition, housing, education, and urban planning in health. They and their affiliated charitable foundations are getting more involved on these issues as a way to improve the health of patient populations and reduce medical costs.
McClellan agrees that health plans and providers have an important role to play. “Health has physical, mental, and social components,” he says. “Health plans are looking at this broader definition of health to create better value for beneficiaries and payers.”
There’s broad agreement on the importance of addressing social factors such as widening income gaps, joblessness, poor schools, and poor housing to improve health. Still, there’s likely to be a strong political overlay, for both ideological and budgetary reasons, to any ambitious proposals to shrink these social disparities.
David R. Williams, a Harvard School of Public Health professor who is serving as staff director for the RWJ-funded commission, acknowledges the political realities. “We are looking for solutions that we can come to a consensus on and make progress to improve health,” he says. “We don’t need a social and economic revolution to do this.”
Even though Williams says other countries are doing better at improving on some measures of population health than the United States, he dismisses the idea of looking at effective programs in those countries. “We are looking for programs that would work in the United States,” he says.
Health Plan Efforts
Health plans around the country increasingly are recognizing the importance of improving health by addressing environmental and social factors.
UnitedHealth Group recently announced a 10-year, $100 million initiative to support communities in its home state of Minnesota. The initiative, called United Minnesota, is designed to advance health, education, and social well-being through alliances with community groups that have demonstrated success in improving the quality of life in their communities.
One project United Health is supporting with a $2 million, one-year grant is the Minnesota Early Learning Foundation. It seeks to identify the most cost-effective strategies for preparing low-income children for kindergarten, particularly getting them ready to read, says Daniel S. Johnson, vice president of community and philanthropic affairs for UnitedHealth Group. A United senior executive will serve on the foundation board.
The early learning initiative is conducting pilot projects in four locations—the rural south central counties of Nicollet and Blue Earth; North Minneapolis and St. Paul, with a large African American population; and the relatively affluent suburb of Wayzata. They aim to increase access to quality care for at-risk children, improve the quality of child care, increase parental education, and improve early childhood education policy.
The United Health Foundation also has been involved in broader health promotion work through its long-time sponsorship of America’s Health Rankings. The project annually ranks the states on broad measures of population health, including statistics such as high school graduation rates.
“United increasingly views health as more than health care,” Johnson says. “We very much embrace the World Health Organization definition of health as more than absence of illness.
It’s about physical, mental, and social well-being.”
Still, Johnson doesn’t see United getting directly involved in lobbying for policy changes to address disparities and social factors affecting health. “I’d be surprised if we take it that far.
We want to stay relevant to our mission as a health and wellbeing organization,” he says.
In an example of what is now considered a “traditional” community health promotion project, Priority Health, with half a million members in Michigan, has partnered with the Asthma Network of West Michigan to attack the chronic problem of asthma in patients’ homes. It has received national recognition as the first health plan in the country to take this approach. Many plans have followed its lead.
Mary Cooley, Priority Health’s senior manager for case and disease management, says her plan realized that it was not able to address the environmental triggers for persistent asthma through traditional telephonic case management. So in 1999, Priority Health began reimbursing Asthma Network nurses, respiratory therapists, and social workers to go to members’ homes and look for asthma triggers, such as mold, pets, dust, cockroaches, and smoking.
If the workers find lots of mold, they may recommend encasing mattresses and pillows, pulling up rugs to expose hardwood floors, and quitting smoking. The plan reimburses for up to 18 home visits per member and pays at the skilled home visit rate.
Priority Health reaches about 19,000 asthmatics a year in various ways and serves about 200 people a year through the home-based program.
Kaiser Permanente is another plan that has taken a holistic approach to community health. “We need to create the conditions of health, and that requires more than medical care services, brochures, and pamphlets,” says Loel Solomon, director of community health initiatives and evaluation for Kaiser Permanente in Oakland, California, which has spent $28 million on such initiatives since 2005.
In Commerce City, a largely Latino, working community on the outskirts of Denver, Kaiser is working with the local planning and health departments to incorporate walkability and bikability into the redevelopment plan for the commercial district. In line with that, Kaiser seeks to have a new high school built with safe walking and biking routes to school.
“It involves changes in the way the city is being built that will affect generations,” Kaiser’s Solomon says.
A central element in Kaiser’s work in Commerce City and other areas is collaborating closely with community groups, government agencies, and businesses. This often means bringing together people who otherwise might not be talking, such as traffic engineering and school board officials, according to Solomon.
It’s also crucial to truly enlist grass-roots support. Corina Lindley, who spearheads Kaiser’s Commerce City project, recalls how important it was to persuade Latina women to participate in a walk around the community to evaluate the safety of walking routes for schoolchildren.
“The residents were quite afraid at first,” she says, “but it helped make residents feel more empowered over how the streets are designed.”
Meanwhile, Kaiser has teamed up with the Colorado Health Department and the Colorado Health Foundation to take the healthier community concept statewide in a plan called Live Well Colorado. Rocky Mountain Health Plan recently joined the planning process.
These efforts by health plans and others, as noted in the sidebars, are raising awareness that keeping people healthy requires more than providing good medical care. Health promotion also requires improving home, school, and work environments and rethinking the physical design of our communities.
Ultimately, it means developing policies targeting the social conditions and disparities that prevent people from leading healthy lives.
Editor’s Note: See also our story about the winners of the 2008 AHIP Community Leadership Award for more outstanding examples of health plan involvement in community efforts that transcend health care. C
Harris Meyer is a freelance journalist based in Yakima, Washington who has reported on health care policy for many years.
Flagging Air Quality
F r e s n o C o u n t y , in California’s rich agricultural Central Valley, suffers an astonishing rate of child asthma due to the area’s geographical features, its industrial farming, and the huge amount of truck traffic.
More than 20 percent of the county’s children have asthma, a rate over twice as high as the national average.
In 2002, Anthem Blue Cross, which then served about one in seven children in the largely low-income county through its Medicaid and State Children’s Health Insurance Program (S-CHIP) plans, was seeing 31 emergency room visits per 1,000 members a year due to asthma.
Dan Shydler, Anthem’s regional director for Medicaid programs in Central California, was concerned. Then an environmental catastrophe pushed the problem over the edge. In January 2003, a fire broke out in a Fresnoarea landfill containing lots of tires. It burned for a month. Asthma-related ER visits for Anthem members spiked that month and in the following months, soaring to 41 per 1,000 members a year.
While some said the fire didn’t cause any health problems, Shydler and other Anthem staffers pulled claims data and conducted geospacial mapping. They found that claims for asthma-related ER visits rose wherever the plumes of smoke from the fire traveled. That debunked the argument that the fire wasn’t having any health effects.
Then Anthem took the next step.
“We wanted to see if there was a way to reduce the impact on our members and on the larger population,” Shydler says.
Anthem partnered with the American Lung Association to develop a program in which schools hoisted colorcoded flags, to indicate the air quality for the day, signaling to the community how safe it was each day for children to participate in outdoor activities, such as recess and football.
Anthem helped the schools buy flags, and the Lung Association trained school staff in the meaning and use of the flags. As a result, some schools cancelled football games—no mean feat—and moved recess indoors.
Anthem, which now has 8.7 million total members and 1.1 million Medicaid and S-CHIP members in California, is spearheading a study in conjunction with two universities on the school flag program’s impact on health. The researchers want to know how many schools are using the flag program, how they’ve changed outdoor activity policy as a result, and how the program has affected respiratory distress and asthma claims.
Meanwhile, Anthem has adopted the school flag program as a best practice for its Medicaid services department.
The plan has implemented the program in other parts of California and is planning to roll it out around the country.
Shydler says the experience has given public health officials in the Central Valley a stronger foundation for taking immediate action when such fires occur.
“There’s now more awareness that air pollution has a direct impact on asthma,” he says.
—Harris Meyer
Paths to Fitness
Tw o y e a r s a g o , Blue Cross & Blue Shield of North Carolina partnered with the North Carolina Health and Wellness Trust Fund and a group called Active Living by Design to carry out the Fit Together grants program. Starting last year, the Blues’ foundation offered rural communities up to $40,000 a year over three years to establish programs and modify their infrastructure to encourage walking. Five communities received grants.
Stokes County is building sidewalks that connect the library, the elementary school, the senior center, and shopping areas, and encouraging people to use them. Camden County is building a new, centrally located park, and creating activity programs there. Several of these communities are poor and could not afford to build new sidewalks and parks on their own.
The Blues’ foundation also is funding programs to encourage more walking and running at preschools. Last year, it provided a one-year, $48,000 grant to North Carolina State University’s Natural Learning Initiative, which is working to change the outdoor environment in preschools around the state to increase physical activity.
The program, called Preventing Obesity By Design, includes adding winding paths, stepping stones, and different kinds of plantings, creating visual interest and enticing children to move around more.
“The bottom line,” says Jennifer MacDougall, the foundation’s program manager for its Healthy Active Communities project, “is we’re trying to change these communities so you move as part of everyday life. It’s incredibly successful in some areas, and people are struggling in others.”
At the end of the three-year grant, the foundation will publish case studies so other communities can learn how to do it.
—Harris Meyer
Healthy Relationships
M i k e P al e n cia fl o a t s a series of provocative statements about potentially violent dating situations past 50 or so freshmen and sophomores sitting in the school library.
“I have the right to refuse sex, even if we’ve done it before. True or false?” he asks the girls and boys at Mabton High in Mabton, which serves a large Hispanic/Latino population. “It’s your body,” one girl calls out.
“If someone is raised by parents in a loving relationship, you won’t have a violent relationship. True or false?” A girl calls out “true.” Palencia asks why.
“I don’t know,” she says.
“One-third of teens experience violence in dating relationships. True or false?” There’s no answer from the students. “It’s true,” he says.
Palencia, a community health educator for Planned Parenthood of Central Washington, was presenting a program called “Teen Dating Violence: Love Doesn’t Have to Hurt.” It recently received a $12,900 grant from the Group Health Foundation of Group Health Cooperative.
There are high rates of domestic violence, teen pregnancy, and sexually transmitted disease in the low income Yakima Valley area where he offers the class.
The program teaches teenagers about dating violence—including physical and emotional abuse—and how to avoid it. The teenagers then teach their peers. A Planned Parenthood health educator in the Richland-Pasco- Kennewick area has trained eight teen peer counselors, and they are working with about 400 teenagers a year.
Amy Claussen, the Planned Parenthood chapter’s director of education and training, says avoiding dating violence and gaining power and control in dating situations has a significant impact on a person’s healthy development and lifelong sexuality.
Some Mabton students say the program is helpful because they know kids involved in abusive relationships. “I’ve seen guys taking the back of their hand to girls,” says one young male student.
“They get in a relationship and feel they can control them.”
“The class will help us know how to get out of bad relationships,” says a freshman girl.
—Harris Meyer
Creative Outreach Makes a Difference
Teaching Children About the Link Between the Choices They Make—and Good Health
“In poor communities, we see high levels of obesity, fewer safe places for kids to play outdoors, and a lack of readily available and affordable healthy foods. Many families in these communities, and especially children, do not make the connection between behavioral choices—what and how much to eat, how much to exercise—and health,” says Larry Altman, vice president of corporate marketing and communications at Horizon Blue Cross Blue Shield of New Jersey (BCBSNJ). The issue is a lack of basic health understanding, he says.
One solution is a program whose aim is to improve understanding of the link between social behaviors and health.
Horizon BCBSNJ, through its foundation, sponsored a health literacy program with 10 Boys and Girls Clubs in New Jersey in which teen mentors were trained and paid to read healthrelated books with young children. Sixty-two percent of the children participating in the program increased their standardized reading test scores, and 65 percent of the children increased their knowledge about living healthy lifestyles and proper nutrition.
In 2004, Horizon BCBSNJ developed “Shape It Up,” an interactive educational program for school children between the ages of six and 10 designed to reduce childhood obesity. Age- appropriate demonstrations and materials, complete with cartoon characters, provided children with healthy eating and exercise information as well as nutrition information for parents. The multiyear program, developed with Rutgers University School of Pharmacy, was presented to more than 60,000 school children across New Jersey.
Horizon BCBSNJ also is about to launch the Healthy U program in conjunction with the State Alliance of YMCAs. The program will teach the CAT CH (Coordinated Approach to Child Health) curriculum to more than 18,000 children starting this fall. This curriculum from the University of Texas is designed to teach children that being physically active and eating healthfully can be fun. Past experience with this curriculum indicates that over the next four years the obesity rate among the participants should be reduced by 10 percent or more.
Molina Healthcare is promoting literacy itself. The health plan is partnering with nonprofit organizations in a program called Book Buddies, which promotes family literacy by collecting donated books and distributing them to needy children through community-based organizations and schools. Book Buddies has built more than 35 libraries in Boys and Girls Clubs, schools, and shelters in addition to giving children and adults books to keep. For many it is their first book. Book Buddies distributed over 500,000 books in its first three years of operation.
Meeting a New Mother’s Range of Needs
“CareOregon has a number of programs that focus on helping the whole person,” says Jeanie Lunsford, communications manager. “We recognize that a member’s living situation, support system (or lack thereof), and access to food, shelter, and clothing all have an enormous impact on physical and mental health. One such program, for postpartum moms and infants, just celebrated its first anniversary.”
Becoming a parent is a transition; transitions bring joys and challenges. CareOregon says it wishes to celebrate the joys and ease the challenges for its members by providing new mothers with information and support.
The plan’s CareSupport staff calls new mothers three times in the first two months.
Each call is followed up with a packet of information and a small token, such as a youth health guidebook or miniature frame for baby’s first photo.
The conversations include both health and non-health-related topics. Do the new mothers have a place to live, a support system, or need food or clothing? Staff helps them connect with community groups that can meet their non-health service needs. At the same time, CareOregon screens for postpartum depression, then works immediately with the member and provider if the new mom is exhibiting signs of the condition.
The program’s goal is to support new mothers, infants, and families to assure optimal quality of life, patient satisfaction, and health status. Measurements for the program include member satisfaction, well-child visit adherence, postpartum visit adherence, immunization rate, emergency screening rate, and tobacco cessation rate.
In 2007, 2001 calls were made to new mothers and 1,061 new mothers were provided with assistance. According to CareOregon, the program is being praised by providers in the community, and new mothers have enthusiastically communicated their appreciation. In the words of one member, “I’m happy and surprised that my insurance company would care enough about me and my family’s health and welfare to make calls to see if I’m getting everything I need.”
For more details:
http://www.careoregon.org/carenews/2008/Winter-2008/Moms.html
http://www.careoregon.org/carelink/
Fun Characters in the Classroom Model Healthy Behaviors
Health Care Service Corporation (HCSC), which owns and operates the four Blue Cross and Blue Shield (BCBS) plans in Illinois, New Mexico, Oklahoma, and Texas, is engaged in an innovative childhood obesity prevention initiative. This multistate program is building and improving upon a successful, science-based intervention that took place in the Delta Regions of Mississippi, Louisiana, and Arkansas.
The Delta H.O.P.E. Tri-State Initiative (HOPE ) implemented and evaluated a classroom-based intervention that: (1) used a cast of “OrganWise Guys” fun characters to help teach young children physiology and lifelong healthy behaviors through read-aloud books, games, dolls, and informational videos, and (2) encouraged short bouts of physical activity integrated with academic lessons. The W.K. Kellogg Foundation funded this four-year project (2003–2007), which targeted 30,000 low-income students.
The HOPE model addressed the risk factors for obesity by meeting children where they spend a majority of their day— in the classroom—and by making the academic day a forum where good nutrition and physical activity habits could be initiated for a lifetime. University extension agents in each state, who were trained nutrition education professionals, disseminated these curriculum-linked materials.
Collaboration with the university extension system allowed for the time teachers spent on nutrition education instruction to be “matched” with federal funds via the USDA Matching Funds program.
In reviewing the results of the BMI analysis for approximately 1,400 students in the Delta HOPE project, trends suggest improvement in healthy weight. Between 2005 and 2007, the percentage of students in the obese category declined from 24.43 percent to 20.24 percent. In 2005, 53.13 percent of students had a healthy weight, whereas in 2007, 59.12 percent of students were within a healthy BMI.
In the 2006-2007 school year, HCSC funded a pilot of 20 Texas elementary schools to expand and replicate the HOPE model. This was managed via collaboration with Blue Cross Blue Shield of Texas and the extension service of Prairie View A&M University, also a client of HCSC.
For the 2007–2008 school year, HCSC has funded an additional 80 schools (20 per state) to begin a multi-state BCBS collaborative childhood obesity prevention initiative. Each state is modeling the HOPE project with modifications and state-specific branding, as unique stakeholder partnerships and collaborations for dissemination are being formed.
Farmer’s Markets
Preston Maring, M.D., tried for more than 30 years to get his patients to eat healthier foods, with little success. So he decided to take a different approach.
Five years ago, he organized an all-organic farmers’ market in front of his hospital, the Kaiser Permanente Medical Center in Oakland, California. “Rather than try to influence people one at a time,” he says, “I thought maybe a farmers’ market would be a good way to put out good food as a celebration.”
It was an instant hit. Local residents came to shop, employees strolled out on their break, and patients and visitors emerged from the hospital to look at fresh organic strawberries and peaches.
The success prompted many other Kaiser facilities to start nearby organic farmers’ markets. There are now 30 in six states.
Quite a few, like the newest one in the Watts neighborhood of Los Angeles, are located in low-income, minority neighborhoods. Many such communities lack full-service supermarkets with good, fresh produce sections.
A survey Kaiser did about two years ago at 17 of the farmers’ markets found that 71 percent of people at the market said they were eating more fruits and vegetables because of the market’s presence, and 63 percent said they were trying different kinds of produce.
“I’m your basic guy that’s trying to get someone to eat an arugula salad instead of a bag of Doritos,” says Maring, an OBGYN and the associate physician-in-chief at his hospital, who was never previously involved in population health work.
But Maring didn’t stop there. He thought about how he could extend the benefits of the healthy food to hospital patients who couldn’t walk out to the market. Last year, he arranged to have small- to medium-size farmers who practice sustainable agriculture supply their produce to the hospital food service. So patients get delectable strawberries and peaches on their bed trays.
Kaiser Permanente is now serving local organic produce in patient meals at 19 of its regional hospitals, comprising about onequarter of all the produce served in meals.
Then Maring had another idea. This May, his hospital launched a food box delivery program, available by subscription, to employees. The weekly boxes come from the same farmers supplying the hospital food service. This also helps the local farm economy.
Various Kaiser hospitals have expanded on Maring’s farmers’ market concept in different ways. One hospital sends out a mobile cooking van that offers cooking demonstrations using fresh fruits and vegetables. His own hospital brings elementary and high school students to the market to meet the farmers, sample fresh produce, and interact with pediatricians, nurses, and social workers.
The farmers’ market program has no direct cost to Kaiser other than providing the space and sometimes the permit fee for the markets, which are run by farmers’ market associations.
Maring acknowledges that he can’t prove that the fresh produce programs have resulted in improved health outcomes.
But, he says, “I do know that some of my patients and employees, because of the inspiration of the market, have lost weight. It starts the conversation about good food.”
He also measures success in another way. “One of the most beautiful things I’ve ever seen,” he says, “is little kids sampling pomegranate seeds for the first time and coming up with a purple face and a big smile.”
—Harris Meyer
