Despite more than a decade of government-sponsored anti-obesity campaigns, a reduction in the consumption of soft drinks and a trend of fast-food menus listing calorie counts, obesity rates in the United States are still increasing. Every state in our nation has rates of obesity that are higher than 20 percent. Arkansas has the highest adult obesity rate at 35.9 percent, while Colorado has the lowest at 21.3 percent. And children are following close behind; for the period from 2011 to 2012, 17 percent of young people ages 2 to 19 were obese, and 31.8 percent were considered either overweight or obese
As body mass index (BMI, a ratio of weight to height) rises, so do sick days, medical claims and health care expenditures. According to The State of Obesity, an annual report funded in part by the Robert Wood Johnson Foundation, estimates for health care costs related to obesity range from $147 billion to nearly $210 billion per year. Work absenteeism related to obesity costs approximately $4.3 billion annually.
Clearly, reducing obesity in the American population would translate to fewer doctors’ office visits, medical tests, drug prescriptions, lost work days, emergency room visits and hospitalizations. Weight loss through improved nutrition and increased activity will also help reduce the risk for a range of diseases and ailments, from mental health problems to osteoarthritis and beyond. Beating obesity can lead to a better quality of life – as well as a better bottom line.
Obesity is a complex issue, however. Behavior plays a role: This includes an individual’s diet, activity levels and medication use. Behaviors are also affected by societal factors surrounding food and physical activity, as well as by education level, environment and food marketing.
According to the Centers for Disease Control and Prevention, genetics may also play a part in the development of obesity. Studies have identified a number of genes that may contribute to obesity by increasing an individual’s hunger and the amount they eat.
Preventing weight problems in children can set a course for lifetime health, and addressing obesity and overweight in adults can improve quality of life and reduce current and future health care costs.
At Advanced Medical Reviews (AMR), an independent review organization, a recent case involving a 24-year old morbidly obese woman demonstrates the many factors to consider when covering obesity treatments. The patient requested a weight loss surgery and, while she was obese, she did not meet the criteria for surgery, as these types of surgeries undergo very strict guidelines based on medical evidence.
The patient reported poor dietary habits that did not support her efforts to lose weight as well as failed to meet the criteria of working with a nutritionist. Per the American Society for Metabolic and Bariatric Surgery guidelines, patients should be seen for as many visits as needed to make sure they are living a bariatric lifestyle and making the right dietary choices prior to surgery. Patients need to demonstrate compliance to a bariatric lifestyle, or the outcome can be even more severe than the obesity itself.
“Obesity is a preventable and serious health problem,” said Dr. Louise Alpern, VP of Clinical Services of Advanced Medical Reviews, “and bariatric surgery is appropriate when the proper medical screenings and evidence based guidelines are followed. It is important that we follow these guidelines when selecting candidates for surgery otherwise the outcome may not be as intended.
Medicare leads the way
In 2004, Medicare announced a change in the organization’s policy to acknowledge the seriousness of obesity as a medical condition. Specifically, Medicare removed language in its regulations that said “obesity is not an illness,” and it said it would pay for treatments for obesity that are “reasonable and effective.” Effectiveness would be decided by the usual Medicare process.
Treatments for obesity covered by Medicare are currently limited. The Medicare coverage policy manual approves gastric bypass surgery when used for the treatment of diseases caused by obesity, such as type 2 diabetes and cardiovascular disease. Obesity screening and counseling (individual and group behavior therapy) are also covered services.
Drugs to treat obesity are not included in the Medicare drug benefit, and the medical nutrition benefit is currently limited to only certain diagnoses (like diabetes and renal disease).
The AOTA is closely tracking these changes to Medicare coverage, and the group is planning to petition Congress to seek inclusion of drugs to treat obesity in the Medicare pharmaceutical benefit. They are also waiting to see what the American Dietetic Association decides to do regarding the medical nutrition therapy benefit.
Will changes in Medicare’s approach to obesity lead to changes in other payors’ handling of this growing health problem? The AOTA thinks it is likely.
“Traditionally, what Medicare decides to cover has a powerful ripple effect through the federal-state Medicaid program and in private, commercial insurance. It is our expectation that this will be the case with obesity. However, our health insurance system is very diffuse and it will come down to what states and private payors can afford. Nonetheless, Medicare endorsement has a powerful effect on all payors in the health care system.”
To get an idea of what the future may hold for trends in reimbursable services, payors can read a full report on Medicare obesity coverage issued by the Centers for Medicare & Medicaid Services.