Plans seek solutions to the obesity disease

No matter how you categorize it, obesity is costly in many ways. The American Medical Association (AMA) has classified obesity as a disease, meanwhile, health plans struggle to find ways to manage obesity’s direct and indirect costs. Plans are also casting a concerned eye to the future-and with good reason.

According to a report issued by the Trust for America's Health and the Robert Wood Johnson Foundation, “F as in Fat: How Obesity Threatens America's Future 2012,” current healthcare costs for treating obesity range from $147 billion to nearly $210 billion annually. These costs include treatment for obesity-related diseases, including type 2 diabetes, heart disease, hypertension and certain cancers.

Looking ahead shows more potential bad news. Based on current trends, healthcare costs for treating preventable obesity-related diseases are estimated to increase by $48 billion to $66 billion per year in the U.S., with another $390 billion and $580 billion in annual lost economic productivity.

What concerns health plans the most about projections like these is that there is currently no clear strategy for reducing long-term obesity.

“Health plans are coming around to the reality that not only is obesity a real problem, but it’s a problem without a silver bullet,” says Chris Wasden, global healthcare innovation leader with PwC in New York.

However, there is some qualified good news when it comes to obesity-related costs. Even a small reduction in weight among the effected population can have a significant impact on healthcare costs. More specifically, lowering average body mass index (BMI) by 5% by 2030 could cut these projected costs by anywhere from 6.5% to 7.9%, according to the Trust for America's Health and the Robert Wood Johnson Foundation report.

Behavioral change

Even though bariatric surgery and pharmaceutical options for treating obesity have existed for some time, none of these interventions have proven to be 100% effective at eliminating obesity.

“There are minimal clinical treatments available (to treat obesity) and those that are available often are not covered or are even explicitly excluded by health plans,” says Scott Kahan, MD, director of the Stop Obesity Alliance in Washington, D.C. “That creates a barrier to access.”

Although Kahan emphasizes that bariatric surgery can be a very powerful intervention against obesity, he admits that it is often unrealistic to think that such a complex problem as obesity can be solved with any one-off treatment.

“Rather than trying to find one intervention, we need to find and implement approaches that help over the life course of patients or at least over a larger course of time,” he says.

Most experts emphasize that effective obesity treatment relies on changing patient behavior. Although using available drugs and surgical procedures can help kick start the process by helping people to make dramatic changes and begin to see results, “people still have to change their diets and activity levels to make permanent change,” says Wasden. “Even people who have had bariatric surgery can still be obese.”

Although bariatric surgery programs and other obesity treatments frequently include behavioral components, individual patient behavior remains a wild card.

“You can't control patient behavior,” says Ann Peterson, vice president of physician network operations at Loyola University Health System in Maywood, Ill. “You can only try to influence it through proper programs, screenings, feedback and education.”

Therefore, it follows that efforts to reduce obesity would include expanding reimbursements to include these types of behavioral programs. For example, health plans can consider covering services that support behavioral changes in patients, such as follow-up calls to check on patient progress.

“This type of proactive patient management is not typically eligible for reimbursement,” notes Peterson.

Others would go beyond that.

“There should also be reimbursement for physicians who provide counseling on obesity and related issues,” says Kahan. “That would go very far in terms of getting doctors spending more time with patients to help with these issues.”

Even the AMA’s classification of obesity as a disease could yield new approaches for health plans. For example, some health plans are integrating obesity-related disease management programs with those for other diseases, such as heart failure and diabetes

“Treating obesity as a disease provides a new opportunity for health plans to create legitimate disease management programs,” says Wasden.

Changing the system

Whatever approaches health plans adopt, they are likely to focus quite heavily on specific metrics of success, such as weight loss over a certain period of time, how consistently weight loss is occurring and whether patients keep the weight off.

“Just as plans will not pay for drugs forever if patients are not losing weight, they will only want to pay for programs that work,” says Wasden. “There are some very innovative programs outcome-based programs that would allow health plans to pay for services like a gym membership if patients show that they are going to the gym on a regular basis and losing a certain amount of weight.”

In many ways, these types of approaches mirror the efforts employers are taking when it comes to employee wellness.

“These programs focus on a lifetime of health and that requires a pretty significant change in lifestyle,” says Helen Darling, president of the National Business Group on Health in Washington, D.C.

These employer-provided programs often include health risk assessments and access to health coaching and other supporting programs, such as nutrition counseling and activity-based programs that track activity and eating patterns.

“The best programs will do something like follow individuals’ activity levels combined with a proven nutrition program, along with planned follow up to track whether the individual’s risk factors have changed,” she says.

To follow this example, providers and health plans would have to change. For providers, these new approaches require new business models.

“The reality is that the vast majority of providers have no idea how to provide these services and get paid for it. There is no business model for doctors to make money by prescribing patients activity and nutrition,” says Wasden.

For health plans, a shift away from focusing on reimbursing for drugs and procedures for obesity treatment could lead plans to consider paying for services designed to improve patient nutrition and activity levels.

“Payers will have to be more innovative around payment models and providers will have to be more innovative to get paid for providing these treatments,” says Wasden.