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Supplements Impact of Obesity Interventions on Managed Care
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Caroline M. Apovian, MD, FACP, FACN
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Scott Kahan, MD, MPH
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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
     A 2008 survey queried payers who represented approximately 100 million covered lives and 42 physicians who treat approximately 500 patients monthly who are obese. It found that payers continued to categorize weightloss drugs as lifestyle drugs, or drugs that lack efficacy. Although physicians considered any treatment associated with weight loss of 5% to 10% over 6 months effective, payers required evidence of weight loss of 18% to add a pharmaceutical to their formularies. Payers indicated that they considered bariatric surgery more effective; 88% of payers covered weight-loss surgery. Plans that did cover weight-loss drugs often used high copayments and utilization restrictions to manage these products.11 It is unclear if physician beliefs have changed in the intervening years. Limited pharmacotherapy coverage leaves clinicians and patients with substantial gaps in their options.

     In January 2015, several media outlets reported that although two-thirds of adults are overweight or obese, coverage of weight-loss medications is limited. This report noted one-third of companies did not cover anti-obesity drugs, one-third covered approved drugs with restrictions to limit their use, and one-third covered all FDA-approved weight-loss drugs without restrictions. A spokesperson for
America’s Health Insurance Plans, a trade association, indicated that variability of insurer coverage of antiobesity drugs emanated from questions about safety and effectiveness evidence.40,41 One analyst referred to a 2014 study42 as support for the insurers’ position.
     Notably, the effort to define obesity as a disease may have negative consequences. A study by Hoyt and colleagues found that defining obesity as a disease—implying that bodies, physiology, and genes are malfunctioning— encourages perceptions that weight is unchangeable. The researchers enrolled 185 patients in one study and 182 patients in a subsequent (second) study. The study randomized patients to read a New York Times article discussing the AMA’s decision to categorize obesity as a disease or read an article offering standard information-based public health messages about weight. Then, they conducted a third study that sent a different message: that obesity is not a disease. Findings revealed that participants were more likely to see themselves as healthier and eat more unhealthy food if their overweight status was classified as a disease. For the researchers carrying out the study, the findings implied a sense of demotivation in the subjects with excess weight. The study authors concluded, “this message [that obesity is a disease] cultivates increased body satisfaction, but also undermines beneficial self-regulatory processes in obese individuals.” When patients saw their weights as fixed, they also inferred the problem was out of their control. This perception increased with increasing body weight.42

Managed Care Considerations
     
MCOs consider a number of factors when determining formulary placement of drugs. Concerns regarding long-term durability, long-term patient adherence, and impact on meaningful clinical end points have all been considered by MCOs in coming to the formulary determinations. Good quality evidence of long-term effectiveness is critical. Currently, most evidence for weight-loss drugs is for periods of one year or less. A 2014 meta-analysis, however, provided some evidence of the long-term effectiveness of anorexic drugs.30
     This meta-analysis included studies published before September 2013 and defined long-term use as use for one year or more. It determined that long-term use of obesity medications, as an adjunct to lifestyle interventions, produced weight loss ranging from 3% for orlistat and lorcaserin to 9% for maximum-dose (15/92 mg) phentermine/topiramate ER compared with placebo. It found the proportion of patients achieving clinically meaningful (weight loss ≥5%) results was 37% to 47% for lorcaserin, 35% to 73% for orlistat, and 67% to 70% for maximum-dose phentermine/topiramate-ER. A key finding was that patients who took these drugs had improvements in cardiometabolic risk factors better than the placebo groups. However, none of the studies included demonstrated reduced cardiovascular morbidity or mortality. This meta-analysis also found noradrenergic medications (phentermine, diethylpropion, phendimetrazine, and benzphetamine, which have only been approved for short-term use) were most frequently used long term and off label by providers. The meta-analysis concluded that discontinuing medication in patients who do not respond with weight loss of at least 5%, and who, therefore, have little prospect of long-term benefit, could decrease risks and costs for patients.30

Adherence: a Concern
     
MCOs have often cited adherence and persistence to medications as rationale for preventing coverage of weight-loss medications, noting that real-world evidence has not been generated to support outcomes consistent with the randomized controlled trials. Although no studies have been published specifically assessing adherence to weight-loss medication, a few have looked at adherence to weight-loss programs in managed care. These may form models by which incentives to increase adherence to weight-loss drugs could be developed. All of these drugs require adherence to lifestyle interventions to be effective. For example, a 2013 study by Rothberg and colleagues evaluated 3 interventions intended to result in weight loss. In this study, an MCO identified 1138 adult
patients who were obese and offered them paid enrollment in weight-management programs. The plan also volunteered to move participants into better (enhanced) benefit levels. Participants selected an in-house intensive medical weight-management program (n = 153), a commercial weight-loss program (n = 439), or a commercial pedometer-based walking program (n = 432). The offer was declined by 114 members. The researchers assessed BMI, blood pressure, lipids, glycated hemoglobin (A1C) or fasting glucose, and per-member per-month costs one year before and one year after program implementation.43

     
At one year, 79% of participants remained in their preferred programs and had attended more than 80% of required sessions. All participants experienced improved clinical outcomes and reduced rates of increase in direct medical costs, compared with the 10% of members who declined participation. Women were more likely to choose the commercial weight-loss program, while men preferred
the pedometer-tracked walking program. The researchers found that in the short-term, these interventions were not cost-saving and pharmacy costs were unchanged; however, participants’ direct medical costs did not grow over one year, while non-participants’ costs did. In addition, researchers projected that, over time, this program would recoup the investment and save money.43
     
A February 2016 study by Patel and colleagues assessed financial-incentive designs to increase physical activity and enrolled 281 adult employees with BMIs of 27 kg/mor more and a mean BMI of 33.2 kg/m2. The researchers randomly assigned participants to one of 4 arms (control group with daily feedback or 1 of 3 financial-incentive programs with daily feedback). The financial incentives
included a gain incentive ($1.40 given each day the goal was achieved), lottery incentive (daily eligibility [expected value approximately $1.40] if goal was achieved), or loss incentive ($42 allocated monthly upfront and $1.40 removed each day the goal was not achieved). Participants were given a 7000-step daily goal and followed for 13 weeks initially, and then 13 weeks with daily performance
feedback but no incentives. A key component of the program was use of smartphone technology to monitor steps, an intervention that the researchers described as requiring little effort from participants.44
     Participants in the control group met their goals 30% of the time. Participants in the gain-incentive, lottery-incentive, and loss-incentive groups met their step goals 35%, 36%, and 45% of the time. Although the loss-incentive group had a significantly greater mean proportion of participant days achieving the goal than control, the adjusted difference in mean daily steps was not significant. During follow-up, at least 95% of participants completed the 13-week intervention, but daily steps decreased for all incentive groups and were similar to control levels.44

    
Aside from financial incentives, MCOs continue to explore other cost-effective and easy-to-implement strategies to improve adherence and compliance for their large member populations. One area that has been explored is the use of technology to counsel or encourage patients to lose weight or maintain weight loss. A 2006 study of weight-loss interventions in a managed care setting randomized patients (n = 1801) to 1 of 3 arms: usual care (which included low-cost weight-management programs), 30 mailers, or 30 phone interventions. The researchers followed the study intervention and patients’ participation in other weight-related programs for 24 months.45

     
Patients in the mail and phone groups reported weight losses of 2.2 kg and 2.4 kg, respectively, at 18 months, while those in the usual care group reported a median loss of 1.9 kg. Thus, all groups lost a similar amount of weight. The researchers found similar results at 24 months, with weight losses of 0.6 to 1 kg reported. They saw that participation dropped after 6 months, and those who continued to participate were more likely to lose or maintain their weight. The cost-effectiveness of phone counseling was $132/kg of weight lost, and for mail and usual care, cost-effectiveness was approximately $72/kg of weight loss. These researchers concluded that to be successful, interventions need strong behavioral messages and engagement strategies.45

    With mail and phone communication rapidly becoming outdated, interventions that use modern technology are the next step in weight-loss interventions. In 2015, Levine and colleagues published a systematic review that assessed technology-assisted weight-loss interventions in the primary care setting. Studies evaluated were published between January 2000 and March 2014. They found 16 studies, 12 of which reported positive results of 0.08 to 5.4 kg of weight loss compared with controls. In these studies, 5% to 45% of patients lost at least 5% of baseline weight. Forty-four percent of the trials used physicians as the lead healthcare clinician, although programs led by other personnel tended to have better results. Most of the studies had patients monitor their own weight, and 63% employed web-based applications.46

 
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