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Caroline M. Apovian, MD, FACP, FACN
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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
     The researchers found that interventions with clinician-guided software or feedback from personnel seemed to be associated with more weight loss than fully automated interventions. Only 1 study with a fully automated program was a positive trial; 11 of the studies with personnel-delivered feedback were positive. Because self-monitoring, in-person and remote feedback, and targeted, structured lifestyle coaching are proven weightloss tools, this was not surprising. Unfortunately, only 2 of the studies used publicly available technologies, and the authors noted that, in terms of pragmatism, many of the interventions were intrusive or inflexible.46 However, these types of interventions still hold promise.

     The studies described above demonstrate that lifestyle interventions and the use of various tools can help clinicians offer potential benefits to patients trying to lose weight, but they remain an adjunct to an overall weight-loss plan. Most patients lost only small amounts of weight during these studies. The Endocrine Society’s clinical practice guideline unequivocally states that using approved weight-loss medication (vs no pharmacologic therapy) promotes long-term weight maintenance and amplifies adherence to behavior changes. They reiterate that weight-loss drugs ameliorate comorbidities such as hypertension, dyslipidemia, type 2 diabetes (T2D), and obstructive sleep apnea.47

Patient Education

       Patients’ understanding of their care remains a linchpin to achieving desired outcomes for any chronic condition. Understanding the pathophysiology of the condition, including the reasons for the chosen approach and the benefits and risks of the treatments, helps better engage patients in their care. In addition, these patients are more likely to succeed in achieving mutually agreed-on goals.
Healthcare providers, such as pharmacists and physicians, need to work closely with patients to ensure they understand the tools available to them and use the tools correctly. With pharmaceuticals, patients need comprehensive counseling and close monitoring. Each product has unique side effects and properties, and clinicians need to be familiar with key counseling points (Table 13,6,32-35,48-54).
     Obesity is like other chronic conditions and remains a challenge to manage. The prospect of making lifelong changes is daunting for patients, and interventions are costly for healthcare payers. Health at Every Size (HAES) is a trans-disciplinary movement that proposes a shift in focus to weight-neutral outcomes. Proponents have conducted randomized, controlled clinical trials and found significant and clinically relevant outcomes. These include improved blood pressure, blood lipids, health behaviors, and psychosocial outcomes. Advocates for HAES indicate that the program achieves these health outcomes more successfully than weight-loss treatment and with less stigma than weight-focused programs.16
Patient success is often contingent on support from the healthcare team. Clinical management interventions, often called intensive behavioral therapy (IBT) and/or lifestyle modification, are covered elsewhere in this supplement. Although clinical trials of IBT often have promising results, they generally yield modest effects on glycemic control, cardiovascular risk factors, and BMI.36,55-59 Documented success in real-world settings has been elusive.23 Interventions used in clinical trials are often more resource-intensive than the typical healthcare plan will cover. Unreimbursed expenses associated with training time for the multidisciplinary team and multiplepatient visits for office visits or group sessions make this approach less tenable for many providers and health systems.14,23 Physicians often lack the tools or support systems to address weight management and are forced to manage its consequences instead.13,14 
As more effective long-term medications become available, guidelines for the management of obesity have been in a state of flux. Several guidelines are now available that address obesity (Table 21,43,47,54). They advocate for a weight reduction of 5% or more and to prevent further weight gain; weight loss of this magnitude can significantly improve T2D, cardiovascular disease, and quality
of life. Some also recommend medications approved for chronic weight management as an adjunct to behavioral therapy for diet and exercise. The guidelines also make an important tangential point: medications that patients who are overweight or obese take for comorbidities may have adverse effects on their BMIs.
Bariatric Surgery
For many patients who have been unsuccessful in achieving their weight-loss goals, bariatric surgery remains an intervention of last resort. Recent published studies have shown the positive impact of bariatric surgery on patients with T2D who were not obese. Increasingly, bariatric surgery is being considered as an earlier treatment choice. Most widely used methods of bariatric surgery rely on either restrictive methods, such as laparoscopic adjustable gastric banding or sleeve gastrectomy, or malabsorptive methods, such as Roux-en-Y gastric bypass or duodenal switch procedures. Bariatric surgery is associated with up to a 75% to 80% loss of the patient’s excess weight. Only gastric bypass surgery has demonstrated long-term efficacy (although it is sometimes not sustained) for patients who are morbidly obese, but it has associated morbidity and mortality risks.23 Not everyone is a candidate for surgery. Surgeons will screen patients to ensure they are healthy enough to tolerate the selected surgical procedure, and they will also screen for psychological health and the ability to understand the need to make major lifestyle changes after surgery.60 Long-term risks include bowel obstruction, dumping syndrome (diarrhea, nausea, vomiting), gallstones, hernias, hypoglycemia, and malnutrition.2
    Many MCOs do not cover bariatric surgery for the same reasons weight-loss medications have faced barriers. Early bariatric surgery had a number of problems and outcomes were not guaranteed. State and federal legislation have increased the requirements for many MCOs to cover at least some of the procedures, but complete insurance coverage remains unavailable for many patients. Improvements in operative techniques and post-operative management, such as the development of laparoscopic surgery, have reduced much of the post-operative morbidity and associated costs. This has caused some MCOs to rethink their coverage positions and open coverage to some, if not all, procedures.23,61,62 A number of studies provide data about long-term outcomes (Table 361-65).

Managed Care and Pharmacologic Coverage
    Several determinants influence MCO decisions to add—or not to add—a weight-loss drug to the formulary. Table 47,22,30,65-72 illustrates some of the deterrents and triggers encountered by MCOs in making their coverage decisions.7,23, 31,65-73 MCOs rely on evidence to make decisions, and often it takes time for researchers to assemble the type of information needed. As data documenting the cost benefit of medical weight management accumulates, and federal mandates to increase coverage are implemented, managed care coverage will increase.
Examining the Triggers for Coverage
     Several triggers—federal mandates, quality measures, and guidelines—are currently being developed, publicized, and implemented. As all stakeholders in obesity become more aware of available interventions and the potential for successful weight reduction, acceptance will grow. Regarding cost savings, Cawley and colleagues demonstrated that health plans could expect savings of approximately $2000 per year in medical costs when a patient whose BMI exceeds 40 loses at least 5% of baseline weight; the greatest savings accrue from the first 5% of weight loss. Patients who have comorbid T2D also benefit from reduced risk of progression to significant comorbidities, so the savings are expected to be greater.74 Given the steep rise in T2D medication prices over the last 2 to 3 years, with prices increasing more than 25% for the category, pharmacologic cost offsets will allow the cost offset from surgery to accrue quicker. Actual cost savings to the plan and members will also occur in a timeframe meaningful to most MCOs.
     In the elderly population alone, Medicare could save a considerable amount of money if seniors with BMI greater than 30 (or >27 with at least 1 weight-related comorbidity) lost 10% to 15% of their weight using weight-loss drugs. Permanent weight loss of 10% to 15% is estimated to save $9445 to $15,987 in gross per capita savings over a lifetime, $8070 to $13,474 over 10 years. Even if patients regain some weight, Medicare could accrue estimated savings of $7556 to $11,109 over each patient’s life, $6456 to $8911 over 10 years.75
Additionally, medically supervised weight loss can significantly decrease medication expenses associated with obesity comorbidities, especially T2D. Cawley’s 2012 research retrospectively analyzed data from 589 obese patients, mean age 49, who participated in a weight-loss program for at least 16 weeks between 2009 and 2012. At baseline, patients took an average of 4.6 medications, of which 1.6 were for hyperlipidemia, gastrointestinal reflux disease, hypertension, or T2D. Patients chose from 3 types of 1200-calorie-a-day meal plans after counseling: 40% chose complete meal replacement, 40% chose 800 calories from meal replacements plus one regular meal, and 20% followed a tailored healthy diet. The program offered weekly physician visits and weigh-ins, counseling sessions with a dietitian and an exercise physiologist, and group education and discussion sessions. Patients in all arms lost roughly 17.5% of their initial body weight. The average overall monthly wholesale cost of the studied medications fell from $150 to $77, with the largest reduction in T2D medications. One shortcoming of this study is that it did not factor in the annual cost of the weight-loss program ($2000/patient).7,74
Increasingly, guidelines promote use of weight-loss medications for initial weight loss and for long-term weight maintenance. They indicate that weight-loss medications ameliorate comorbidities and amplify adherence to behavior changes. Prescribing these drugs may improve physical functioning and allow individuals who are obese to engage in more physical activity.47

Obesity is a chronic condition with multiple factors, internal and external to the individual, contributing to its development and maintenance. Regardless of the contributing factors, obesity is a primary driver of healthcare costs because of its association with many comorbid conditions. Studies have demonstrated that losing weight to a normal range, at nearly any age, results in improved health and quality of life and leads to cost savings. More studies are needed, however, to identify long-term (5- to 10-year) gains achieved by employing weight-loss strategies, including pharmacologic, conservative, or surgical ones.
      However, because obesity is a complex condition with multiple contributing factors, the most effective approach to achieving successful long-term weight loss would seem to be a multidimensional/multipronged one, using all currently available tools. It seems reasonable to consider pharmacologic management, in addition to vigorous lifestyle and dietary management, and possible surgical interventions for all individuals with obesity. Clinicians will need to tailor this multimodal approach to individual patients. Pharmacists can play a crucial role in bridging the gap between patients and their physicians and educating them about the various resources at hand to better optimize their care.
     The cost-effectiveness of the interventions needs to be addressed. Current studies lack the economic evidence to support many MCOs providing coverage for pharmacologic, surgical, or even conservative lifestyle interventions. It is paramount that pharmaceutical manufacturers invest in longer-term studies that will demonstrate not only the clinical efficacy of the medications, but the cost-effectiveness of the products long-term to garner greater MCO coverage. Surgical procedures also need to demonstrate meaningful and timely medical cost offsets in a real-world setting. As the
population ages, obesity becomes ubiquitous, and demand for coverage of perceived efficacious therapies grows; it is imperative that evidence be developed to allow for reasonable coverage policies to be made.


Author affiliation: SelectHealth, Salt Lake City, UT.
Funding source: This activity is supported by educational grants from Novo Nordisk and Takeda Pharmaceuticals U.S.A., Inc.
Author disclosure: Dr Schaecher has no relevant financial relationships with commercial interests to disclose.
Authorship information: Concept and design, drafting of the manuscript, and critical revision of the manuscript for important intellectual content.
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