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Obesity treatment in state insurance plans improving, gap still exists
Medicaid and state employee health insurance programs are improving their coverage for adult obesity, but a treatment gap still exists, according to findings published in Obesity. The gap refers to a growing acceptance of treatments to address mild and severe obesity, but not moderate cases, which may be more effectively treated with drug therapies.
“Although initiatives aimed at primary prevention of obesity should always be considered as a first line of defense, nutritional counseling, pharmacotherapy and bariatric surgery are all effective strategies that support clinically significant weight loss (5% reduction in body weight) for persons with established obesity. Nonetheless, these evidence-based treatment modalities are seldom applied in practice,” William Dietz, MD, PhD, director of the Sumner M. Redstone Global Center for Prevention and Wellness at the Milken Institute School of Public Health at The George Washington University, and colleagues wrote. “Along with lack of training in obesity management, health professionals frequently cite limited reimbursement for obesity-related services as a barrier to delivering appropriate care.”
The researchers reviewed Medicaid and state employee health insurance plans in all 50 states and Washington, D.C., with specific emphasis on select documents, such as fee schedules and drug formularies, and then compared the 2009-2010 plan year with the 2016-2017 plan year for analysis.
Based on the review, the researchers found that nutritional counseling, pharmacotherapy and bariatric surgery were offered by more state insurance programs in 2017 vs. 2010. Nutritional counseling increased by 75% (24 states in 2010 vs. 42 in 2017), pharmacotherapy increased by 64% (14 states in 2010 vs. 23 in 2017) and bariatric surgery was up 23% (35 states in 2010 vs. 43 in 2017). For those with Medicaid, nutritional counseling increased 122% (9 states in 2010 vs. 22 in 2017), whereas bariatric surgery, which was already largely adopted, according to the researchers, increased by 9% (45 states in 2010 vs. 49 in 2017). Drug coverage remained the same, with 16 states offering obesity pharmacotherapies in 2010 and 2017.
Comprehensive coverage, which incorporates all three obesity treatments (counseling, pharmacotherapy and bariatric surgery), was offered by six states in Medicaid, which was up from four in 2010. State employee programs that offered comprehensive coverage increased from seven to 19. Bariatric surgery was covered by both Medicaid and state employee plans in 42 states, whereas 16 and seven states, respectively, offered nutritional counseling and pharmacotherapy in both programs.
The researchers noted that for prescriptions in Medicaid programs, six states “reimbursed substantially.” The researchers said obesity drugs are being covered by fewer Medicaid programs since 2009 even as the FDA has approved such medications as bupropion/naltrexone (Contrave, Nalpropion), lorcaserin (Belviq, Arena Pharmaceuticals) and phentermine/topiramate (Qsymia, Vivus). For comparison, reimbursements for bariatric surgery were provided in 34 states as recently as 2014.
“These results highlight a problematic treatment gap, in which coverage is available for lifestyle interventions (effective for treating mild obesity) and bariatric surgery (effective for treating severe obesity), but not for pharmacologic and medical therapies that are most appropriate for individuals with moderate obesity and a history of unsuccessful weight management efforts,” the researchers wrote. “Although prevention must be a high priority, uniform coverage of evidence-based treatment modalities is essential to manage patients with obesity.”
Additional restrictions to coverage included annual or lifetime caps, differences in coverage based on specific plans and serious comorbidity requirements. The researchers also noted that some states do not consider obesity a disease and thus do not provide coverage at all. Uncertainty about usage even when coverage is available makes for an unclear picture of how much obesity treatment is improving in practice, according to the researchers.
“If policymakers do not recognize obesity as a serious chronic disease, they are unlikely to reimburse for obesity prevention and treatment services,” the researchers wrote. “Similarly, scarce or absent guidance on the appropriate provision of obesity-related services in provider manuals and other plan communications likely deters health professionals from addressing obesity with their patients.” – by Phil Neuffer
Disclosures: Dietz reports he is on the scientific advisory board for Weight Watchers and received personal fees from RTI. Please see the study for all other authors’ relevant financial disclosures.