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Stumbling Toward Access to Evidence-Based Care for the Chronic Disease of Obesity

Theodore K. Kyle, RPh, MBA: and Fatima Cody Stanford, MD, MPH, MPA
Many hoped the 2013 declaration by the American Medical Association that obesity is a disease would open the door to improved coverage for pharmcotherapy. That did not happen right away, but signs of change are emerging.
One of the most substantial medical and financial threats to American healthcare is untreated obesity. Although options and guidelines for pharmacotherapy are growing, access to care is falling behind advances in treatment.


A COMPLEX, CHRONIC, AND COSTLY DISEASE
 
Obesity is a complex, chronic, and costly disease that has been shown to be the key driver behind 4 of the 10 most deadly and expensive diseases worldwide—ischemic heart disease, stroke, hypertension, and diabetes. More than one-fourth of total healthcare expenses in the United States are attributable to the rise in the prevalence of excess weight and obesity.1 Obesity has been characterized as the greatest threat to American health for this century,2 and it is rapidly becoming apparent that obesity will soon undermine the affordability of American healthcare, due to the epidemic of chronic diseases it is causing.3
 
In 2013, the American Medical Association (AMA) joined with the National Institutes of Health, the Obesity Society, the American Association of Clinical Endocrinologists, and the Endocrine Society in recognizing obesity as a complex chronic disease that requires a range of interventions for treatment and prevention.4 Because of the symbolic significance of this decision, it has been both hailed as a significant milestone to pave the way for more evidence-based obesity care and criticized by others as “medicalizing” a condition associated with unhealthy lifestyles.
 

ACCESS TO CARE HAS BEEN LIMITED AND EXTREMELY VARIABLE
 

Historically, access to evidence-based care for obesity has been limited by the small number of healthcare providers skilled in obesity treatment, by inadequate treatment options, and by poor coverage in health plans. Responding to the need for more skilled providers, the American Board of Obesity Medicine has now certified 1182 diplomates in the emerging specialty of obesity medicine.
 
The number of diplomates continues to grow, with more than 400 physicians taking the exam in 2014.5,6 The primary tools for evidence-based obesity care are intensive behavioral therapy (IBT), pharmacotherapy, and surgery. Coverage for IBT is improving under the Affordable Care Act (ACA) because of the requirement that effective preventive services (as determined by the US Preventive Services Task Force) be covered by health plans without any cost to patients. IBT is one of these services.
 
As evidence for the effectiveness of bariatric surgery has grown, coverage for bariatric surgery by health plans for people with severe obesity has also increased, though both patients and surgeons report that problems remain.

Coverage for pharmacotherapy has been the most restricted of the options for obesity treatment. Drugs used for obesity treatment often have been considered “lifestyle” drugs and have been routinely excluded from prescription benefit programs, as is notably the case for Medicare Part D. In 2010, most health plans reported that 20% or fewer employers were including coverage for obesity medications in their benefits. Under the ACA, while 23 states classify bariatric surgery as an essential health benefit, only 5 states classify medical obesity treatment as an essential benefit.8 Poor coverage for obesity medications has been identified as a key barrier to the development and introduction of improved therapies.9
 
Limited coverage of pharmacotherapy for obesity leaves both clinicians and patients with a substantial gap in options. Between low success rates with diet and exercise and much higher efficacy at a much higher cost with bariatric surgery, new and effective obesity drugs are often unaffordable.
 


 
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