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The Role of Managed Care Organizations in Obesity Management
Kenneth L. Schaecher, MD, FACP, CPC
Impact of Obesity Interventions on Managed Care

The Role of Managed Care Organizations in Obesity Management

Kenneth L. Schaecher, MD, FACP, CPC
In the United States, obesity is characterized as this century’s greatest healthcare threat. The American Medical Association and several other large organizations now classify obesity as a disease. Several federal initiatives are in the planning stages, have been approved, or are being implemented to address the disease. Obesity poses challenges for all healthcare stakeholders. Diet and exercise often are insufficient to create the magnitude of change patients and their attending healthcare providers need. Managed care organizations (MCOs) have 3 tools that can help their members: health and wellness programs focusing on lifestyle changes, prescription weight-loss drugs, and bariatric surgical interventions. MCOs are addressing changes with national requirements and are responding to the availability of new weight-loss drugs to help their members achieve better health. A number of factors either deter or stimulate the progress of weight loss therapy. Understanding how MCOs are key to managing obesity at the local level is important for healthcare providers. It can help MCOs and individual healthcare providers develop and coordinate strategies to educate stakeholders and better manage overall care.
Am J Manag Care. 2016;22:S197-S208
     Obesity (body mass index [BMI] ≥30 kg/m2)1 is a challenge for all healthcare stakeholders. Gaining weight is easy; losing excess pounds, however, is difficult for most people, and it is especially hard as individuals get older and their metabolism slows naturally. People who lose weight the old-fashioned way—by cutting back on intake and increasing exercise—often regain some or all weight that they originally lost or gain even more. For people who are obese or extremely obese (BMI ≥40 kg/m2), diet and exercise are often insufficient to create the magnitude of change they need.2 They may need additional tools.

     Managed care organizations (MCOs) have 3 methods to help their members move toward optimal weight and better health: health and wellness/lifestyle modification activities, prescription weight-loss drugs, and bariatric surgical interventions.3,4 Not all MCOs cover all of these interventions.5 This article examines available evidence for weight-loss drugs and bariatric surgery and highlights MCO strategies and concerns.


National Policy, Medical Acceptance

More than 25% of American healthcare expenses are attributed to the rise in the prevalence of excess weight and obesity.6,7 Because of this and obesity-related medical complications, the US Department of Health and Human Services and the Department of Agriculture jointly established Dietary Guidelines Advisory Committee; they have characterized obesity as this century’s greatest threat to American health.8

In June 2013, in an effort to elevate awareness of the importance of obesity management, the American Medical Association (AMA) House of Delegates declared obesity a disease. This was done despite concerns voiced by its Committee on Science and Health that BMI (the measure most often used to diagnose obesity), is, in its opinion, imperfect.3 The committee noted that BMI is a crude predictor of cardiometabolic health and mortality.9 The AMA took action in response to the increasing number of physicians urging them to do so, believing this would force MCOs to provide coverage of the many bariatric services not covered at the time. With this endorsement, the hope was that insurers would improve coverage of the full range of obesity interventions,10 especially because
many prescribers rank reimbursement as important as efficacy and safety when they prepare to prescribe weightloss interventions.11 Several organizations, including the National Institutes of Health,12 the Obesity Society,1 the American Association of Clinical Endocrinologists,13 and the Endocrine Society,14 have declared obesity a disease and recognize its complex nature. These organizations also have acknowledged the need for a variety of treatment and prevention interventions.3,12-14
Notably, a well-structured 2013 systematic review found that individuals with grade 1 obesity (BMI 30-35 kg/m2) and individuals of normal weight (BMI 18.5-25 kg/m2) have similar risks of all-cause mortality. Individuals who are heavier than 35 mg/kg2, however, are at increased risk of mortality.15 Increased weight has also been shown to increase stigma, risk of mood disorders, poor body image, and bad eating habits,16 as well as cause stress and decrease activity.17,18 A newer tool, the Edmonton obesity staging system, has been used on a small scale since 2011; it addresses some of the BMI’s shortcomings and augments clinical assessment. Its 5-point ordinal scale incorporates the individual’s obesity-related comorbidities and functional status. Studies have shown it to be a strong, independent predictor of increasing mortality, and its clinical utility is evolving.19 However, until experts develop a better measure of obesity,many stakeholders will continue to use BMI.
     In 2014, the AMA House of Delegates took a further step to bring obesity into the limelight, resolving to campaign for patient access to all evidence-based obesity treatments, including pharmacotherapy.20 These actions have no regulatory repercussions and are symbolic. Regardless, they heightened awareness of the nation’s obesity problem and its ramifications. One possible measure of the impact of the AMA’s actions may be the number of physicians certified as American Board of Obesity Medicine (ABOM) Diplomates since 2013. ABOM is the only organization that certifies physicians in obesity management,and the increasing number of certified providers reflects increasing acknowledgment that obesity is a complex disease that requires a special skill set to manage. The orgaorganization reports a record number of physicians applied to take the 2015 ABOM certification exam—a 27% increase from 2014. Today, ABOM has certified more than 1200 physicians from a wide range of medical specialties (eg,internal medicine, family medicine, endocrinology, and pediatrics) in North America.21
Other evidence highlighting the impact of obesity on society can be found in legislative and regulatory initiatives. In 2013, the Treat and Reduce Obesity Act was introduced in the US House of Representatives and Senate. If it had passed, this bill would have improved Medicare beneficiaries’ access to weight-loss counseling and new prescription medications for chronic weight problems. Despite bipartisan support, it failed to gain the traction it needed to pass. It was reintroduced in May of 2015 and is without any recent action. This bill would require the Secretary of Health and Human Services to make recommendations to Congress within one year of its implementation, and every 2 years afterwards, to combat obesity; it remains in committee at this time.22 A different federal action, the Medicare Shared Savings Program (MSSP), has established accountable care organization (ACO) measures that track BMI screening and follow-up. Experts estimate that more than 4 million Medicare beneficiaries will be affected.23-25 In addition, to be accredited as an ACO by the National Committee on Quality Assurance (NCQA), organizations need to track BMI screening and follow-up. Screening for being overweight or obese is now on the nation’s healthcare radar.
     One ramification of the Affordable Care Act (ACA) passage was the creation of guidelines for preventive coverage with no cost share to members, based on US Preventive Services Task Force (USPSTF) recommendations. The ACA requires USPSTF A or B recommendations to be covered as preventive care. Because the USPSTF recommends screening all adults for obesity,26 patients with a BMI of 30 kg/m2 or higher should be offered or referred to intensive,multicomponent behavioral interventions. A range of obesity interventions should be covered. However, a 2014 study, funded by the Robert Wood Johnson Foundation,of states’ classification of services as “essential” under the ACA found that 23 states categorized bariatric surgery as an essential health benefit, but only 5 states classified medical obesity treatment as essential.27 These efforts are influencing coverage changes affecting the care of patients who are overweight or obese.
     Since 2014, all health plans serving federal employees are required to cover weight-loss drugs.28 Additionally, individual and small-employer group exchange plans are required to cover intensive behavior counseling for patients with a BMI greater than 30 kg/m2. In the summer of 2015, the National Conference of Insurance Legislators resolved that state legislatures should provide for coverage of the full range of obesity treatment, including pharmacotherapy and bariatric surgery.29 More changes are expected to follow.

Managed Care Strategies
     Historically, few FDA-approved medications have been specifically indicated for weight loss. Phentermine (Adipex-P) as a single agent was the only approved drug for weight management, but its long-term effectiveness was not established; most phentermine studies were shorter than 6 months in duration, and none of the studies met the FDA’s current efficacy benchmarks.30 Until mid-2012,
orlistat (Xenical) was the only FDA-approved pharmacotherapy available for long-term use in the United States.31 Since 2010, however, the FDA has approved 4 new obesity medications (lorcaserin [Belviq], phentermine/topiramate [Qsymia], bupropion/naltrexone [Contrave], and liraglutide [Saxenda]) based on approval criteria that each drug was associated with sustainable weight loss of
5% or more (on average or in more than 50% of patients treated).32-35 In the managed care setting, certain facts about weight-loss drugs inform decisions:
     • Long-term studies of the older noradrenergic agents (phentermine, diethylpropion, phendimetrazine, and benzphetamine) with long treatment durations, adequate sample sizes (more than 50 participants), or acceptable attritions are not available.30
     • Many of the newer drugs were approved based on studies of longer duration that demonstrated sustained weight loss and durability of effect, and additional studies are being conducted.32-35
     • Plans must consider the number of patients who may need or want these drugs, the potential for good outcomes, comparable drugs, and necessary support programs.36

Often considered lifestyle drugs in the past, obesitydirected pharmacotherapy was routinely excluded from prescription benefit programs. For example, when the Medicare Part D program was created in 2003,37 it contained a blanket exclusion for “agents when used for anorexia, weight loss, or weight gain.”38 The Centers for Medicare and Medicaid Services (CMS) reinforced this exclusion in July 2008, indicating the Part D benefit would not cover ‘‘agents when used for anorexia, weight loss, or weight gain (even if used for a non-cosmetic purpose, ie, morbid obesity).”39 Since Medicare Advantage plans (private insurance companies with federal contracts to provide Medicare benefits) were, and still are, allowed to exceed the scope of the Part D-defined benefit, some beneficiaries have coverage.23 Attempts to amend Medicare coverage have been unsuccessful.22

In 2008, most health plans reported that fewer than 20% of employee benefit plans allowed coverage for obesity medications11; however, poor coverage for obesity medications has been identified as a key barrier to the innovation driving manufacturers to develop and introduce even better therapies than those currently available. Manufacturers are reluctant to invest in drugs that will rely primarily on out-of-pocket payments.23

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