The challenge of obesity

The deck is certainly stacked against health plans in their fight to help members lose weight, exercise and eat the right foods. Healthy living is a difficult choice that needs to be made by individuals over and over, every day, for the rest of their lives. To make matters worse, insurers' clinical tools are limited, and available surgical options can be expensive.

"When it comes to combating obesity, we don't know yet what the right answer is," says Lisa Latts, MD, Wellpoint's vice president of programs in clinical excellence. "There is a lot of opportunity for innovation. Creative solutions and innovative partnerships are welcome because there probably will never be a single solution to obesity that works for everyone."

Behavior modification is universally regarded as the best option, but it's not a strategy that health plans-or any individual stakeholder-can implement on their own. Virtually all approaches to fighting the obesity epidemic require partnerships that extend into the workplace, the community and families' own homes. Even legislators are attempting to improve public health through laws that, for example, ban sugary soft drinks in school vending machines or artificial trans fats in restaurant meals.

The National Institutes of Health reported last year that the risks of gastric-bypass and gastric-band bariatric surgery have dropped dramatically and now are no greater than gallbladder or hip replacement surgery. Surgical risks for obese patients are lower than the longer-term risk of dying from heart disease, diabetes and other consequences of carrying more weight than a person's organs can tolerate, according to a 2009 New England Journal of Medicine article.

Among surgical options, the most commonly performed procedure is gastric bypass which has fewer complications than gastric banding, gastric sleeve or duodenal switch, according to the Mayo Clinic. In addition to reducing body weight, it can also improve or resolve a number of obesity-related conditions such as sleep apnea, type 2 diabetes, hypertension and high cholesterol. And it's gaining progressive acceptance in health benefit policies.

About 220,000 people with morbid obesity had bariatric surgery in 2008, with an average cost range of $17,000 to $26,000.

While policies vary, bariatric surgery generally is indicated for adults who have a body mass index (BMI) of 40 or higher, or have a BMI of 35 accompanied by an obesity-related condition, according to the American Society for Metabolic & Bariatric Surgery.

Among the newer surgical options is sleeve gastrectomy, in which the stomach is reduced to a thin "sleeve" about 15% of the original size of the stomach. Recently, Aetna and UnitedHealthcare announced that they would cover the procedure. Previously, it was considered an investigational procedure, but new data support its efficacy and safety.

There is always activity on the pharmaceutical front, given that the potential market for "weight loss pills" is estimated to be more than $1 billion annually. To date, however, most pills that have demonstrated success in helping patients lose weight-including fen-phen and ephedra-have carried significant and potentially life-threatening side effects.

INFLUENCING BEHAVIOR