Obesity Treatment Coverage and Essential Health Benefits
Obesity has become a major health concern in the U.S., with a significant rise in prevalence over the past decades. Recognized by various organizations as a disease, obesity contributes to serious health issues such as heart disease, cancer, and diabetes. Despite its impact, obesity treatment, including bariatric surgery, is not uniformly covered under essential health benefits, with states having the authority to decide on coverage. This disparity highlights the ongoing challenges in addressing obesity as a disease and providing comprehensive healthcare for those affected.
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Essential Health Benefits and Obesity Treatment Coverage
Obesity Life expectancy, smoking prevalence and use of drugs and alcohol have improved over the last three decades In contrast, obesity prevalence has nearly tripled in the last 50 years Over 2/3 of Americans are overweight and obese 35.7% of Americans are obese It is projected that 42% of the population will suffer from obesity by the year 2030 It is major cause of death attributable to heart disease, cancer, and diabetes according to the Centers for Disease Control and Prevention
Obesity is a Disease National Institutes of Health (NIH) recognized obesity as a disease in 1991 American Medical Association (AMA) in 2013 officially recognized obesity as a disease Governmental agencies recognizing obesity as a disease US Internal Revenue Service (IRS) Centers for Medicare & Medicaid Services (CMS) Other organizations supporting surgical treatment of obesity American Heart Association (AHA) American College of Cardiology (ACC) American Diabetes Association (ADA) International Diabetes Federation (IDF)
Obesity Trends* Among U.S. Adults BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5 4 person) 2000 1990 2010 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30%
Essential Health Benefits Ambulatory patient services Prescription drugs Rehabilitative and habilitative services and devices Emergency services Laboratory services Hospitalization Preventive and wellness services and chronic disease management Maternity and newborn care Mental health and substance abuse disorder services, including behavioral health treatment Pediatric services, including oral and vision care
Obesity Is Not Covered Under the Essential Health Benefits Each State decides whether the disease of obesity is a covered benefit within the qualifying health plans participating in the State Health Insurance Exchange 27 states and Washington DC do not cover bariatric surgery Medical treatment for obesity is a covered benefit in only 5 states
Essential Health Benefit Benchmark Plan Coverage of Weight-Related Services AK WA ME MT ND MN NH OR WI NY VT ID SD MI MA RI WY CT PA IA NE OH NJ IN NV IL DE WV UT CO VA KY KS MO MD CA NC DC TN OK AR SC AZ NM AL GA MS TX LA HI FL Does not cover bariatric surgery nor weight loss programs Covers weight loss programs but does not cover bariatric surgery Covers bariatric surgery but does not cover weight loss programs Covers bariatric surgery and weight loss programs Source: Center for Consumer Information and Insurance Oversight summary of EHB benchmark plans based on 2012 benefits STOP Obesity Alliance, Weight and the States Policy Research Bulletin, December 2012. (States that have not selected an EHB benchmark plan defaulting to the largest small-group employer plan in the state.) Current as of 12-10-2012; Coverage may have changed since this printing
Economics of Obesity Excess weight is responsible for 2.8 million deaths worldwide annually Obesity accounts for 21% of national health spending Obesity discrimination plays an important role in lower income and production 9% lower income
Economics of Obesity Obese individuals have 42% higher annual healthcare costs 77% higher prescription costs (as high as 105%) 37% higher primary care costs Obesity raises annual medical costs per obese individual by $2,741 (in 2005 dollars) Obesity increases lifetime medical costs by 50%
Economics of Obesity Productivity Costs Obese individuals compared to healthy weight individuals have been shown to have 3.73 additional days lost annually 1.23 times higher absenteeism rate 194% more likely to use paid time off Greater lost productive time while present at work Bariatric surgery provides immediate benefit by decreasing lost work time and disability Treatment costs associated with bariatric surgery were relatively small compared to economic losses of not treating obesity
Economics of Obesity and Type 2 Diabetes 24 million Americans have Type 2 Diabetes 41% increase in the total costs of treating diabetes was noted from 2007 to 2012 $174 billion to $245 billion
Bariatric Surgery Outcomes Durable weight loss 106 pound mean weight loss after 16 years Remission of Type-2 diabetes (83%) Reduction in mortality from diabetes by 78%
Bariatric Surgery Outcomes Resolution of Obesity-related Medical Problems High blood pressure Sleep apnea High cholesterol Asthma Gastroesophageal reflux Arthritis of weight-bearing joints 61.4% 63.3% 68.9% 61.4% 66% 87.6%
Bariatric Surgery for Type-2 Diabetes Lifetime costs to medically treat a patient with Type-2 diabetes is approximately $300,000 compared to approximately $25,000 for bariatric surgery Total health care costs Increased 9.7% in the first year after surgery, but Decreased by 34.2% and 70.5% in years 2 and 3 after surgery Life expectancy is improved in bariatric surgery patients when compared to medically managed patients Several studies show increased short-term medical costs are increased, but at an acceptable level of cost effectiveness (given that the guideline for cost-effectiveness in the United States is less than $50,000/quality-adjusted life years) $21,973/quality-adjusted life years (QALY) $7,000-$9,000/QALY for gastric bypass surgery $11,000-$13,000/QALY for gastric banding surgery
Cost Effectiveness Analysis Compared 3651 bariatric surgery patients and 3651 matched surgery-eligible control subjects Assessed total healthcare costs 6 month prior to surgery and up to 5 years after surgery Cost savings began accruing as early as 3 months after surgery Total surgery costs were fully recovered after 49 months for open procedures after 25 months for laparoscopic procedures
Cost of Human Lives Mortality rate is 4.5% per year without surgery compared to 1% per year after surgery Only 1% of the eligible population is treated through bariatric surgery About 25% of patients considering surgery are denied approval for surgery at least three times before obtaining approval By then, 60% will report worsening health problems Three of every 100 patients denied surgery will lose their lives in the next year due to deaths that could have otherwise have been prevented with surgery
Bariatric Surgery is SAFE! In-Hospital mortality rate for bariatric surgery is now 0.1 % Gallbladder surgery mortality 0.52 % Hip replacement surgery mortality 0.93%
Denying Bariatric Surgery Not cost effective In the long-term, surgery is less costly Patients in your state are being denied treatment that is widely available to approximately 45% of Americans Consider that therapy for patients with other chronic diseases are not denied coverage treatments are far more expensive and less effective in terms of remission of disease and decreasing disability and increasing productivity Cancer treatments (medical and surgical) Heart surgery
Obesity treatment coverage should be equitable for all Americans, including citizens who are beneficiaries covered through your State s Health Insurance Exchange
