Experts debate cost-effectiveness of treatment, non-treatment of obesity

WASHINGTON — As physicians grapple with providing care for patients with obesity, they also face the question of insurance coverage, cost-effectiveness and what the unknown costs are of not treating obesity, according to experts at the Consensus Conference on Obesity.

“We vilify those who are preventing access because of cost,” Jeffrey I. Mechanick, MD, FACN, FACP, FACE, ECNU, co-chair of the conference and president of AACE, said. “Those particular parties have said it’s more of a lack of scientific evidence.”

Sheela Magge, MD, MSCE, FAAP, who spoke on behalf of the American Academy of Pediatrics, said there is evidence tracking obesity and its faster growth in children, yet there is not sufficient coverage.

“It’s very difficult to implement even what the evidence supports when we’re not getting coverage for it,” she said. “There’s all this public outcry about the obesity epidemic, but in multi-disciplinary weight management programs for children, it’s very difficult to maintain. In general, they all lose money.”

Representatives from the CDC, FDA, NIH and insurance companies said it was not a question of cost-effectiveness, but of effectiveness overall.

Kenneth Snow, MD, representing Aetna, said insurance companies work on a social contract with those who pay into Aetna’s programs.

“Evidence does not justify that we can spend your money,” he said. “Can you make a scientific argument that in the population you’re looking at highly likely — not guaranteed — that many of these folks will suffer because of their obesity? … Can you make the argument that the therapy you’re suggesting is very likely to make a difference?”

Still, experts questioned what the cost in both dollars and health would be when considering complications of obesity if it continues on this path.

“What is the cost of not doing anything?” George Grunberger, MD, FACP, FACE, who is on the consensus writing committee, said. “We can’t afford not to do something.”

Yehuda Handelsman, MD, FACP, FACE, FNLA, another committee member, suggested there are data that support the billions of dollars in costs of prediabetes transitioning to diabetes, which he said is intimately tied to the obesity epidemic.

Eric A. Finkelstein, PhD, MHA, an economist from the Duke-NUS Graduate Medical School who specializes in obesity, said the current endpoints of trials are unlikely to affect payers’ willingness to cover obesity treatment, but real-world endpoints such as absenteeism in the workplace or uptake of other medical services due to obesity complications would.

“Moving forward, you’re never going to be able to do the randomized trials using cost-effectiveness as an economic endpoint because the trials would be far too large. I would recommend as you make inroads of getting these things out in the community, you do a really nice job of tracking the economic endpoints in the natural experiment,” Finkelstein said. “The reality is that the data that you get from clinical trials is only marginally relevant to payers.” -- by Katrina Altersitz                                                                      

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Presented at: The AACE/ACE Consensus Conference on Obesity; March 23-24, 2014; Washington, D.C.

Disclosure: The consensus conference is supported by Covidien, Eisai, Ethicon, Novo Nordisk, Takeda and Vivus.