In 1999, 31 percent of adults were considered obese; that increased to 42 percent by 2019. This costs the US Health system 173 billion dollars a year. The disease is associated with cardiovascular disease, cancers, depression, breathing issues, and skeletal issues. Despite this toll on health and cost, 98 percent of Americans do not receive treatment for their obesity. Common misunderstandings of obesity that treat it as a ‘lifestyle problem’ have contributed to policy and practice that enacts hurdle to care delivery.
On March 3rd, I hosted Dr. Louis Aronne of Weill Cornell Medicine, Dr. Daniel Goldin of 645 Medical Associates, PLLC, and Dr. Katherine Saunders of Intellihealth to discuss obesity care and coverage policy. The panelists considered the topic, combining expertise with personal experience, as all three treat patients with obesity and have informed the development of new tools for intervention including medicine and information technology. The event provided viewers with an introductory understanding of the topic by examining how technology and treatment have changed over time, obstacles to care including stigma and bias, and lack of insurance coverage. We discussed how effective treatment may affect long- and short-term costs and health. I summarize some of the key points from that discussion.
Weight gain causes a physiological change making weight loss more difficult. This, combined with genetic and environmental factors, contributes to the complexity of the disease and the challenges to treatment. New drugs are on and entering the market that achieve weight loss at a rate comparable to surgery. One panelist described this as the “golden age” of obesity treatment similar to moments in history that saw the proliferation of medicines for conditions including high cholesterol and hypertension.
Americans pay on average 15 percent out-of-pocket for medications; but 68 percent of the cost for obesity medicines. This failure to cover obesity treatments is partially attributed to the long-standing stigma associated with the disease and its treatments. For example, policymakers decided not to cover obesity medications in original Medicare Part D and coverage is sparse in Medicaid. Policymakers have not changed that Medicare decision despite the introduction of legislation and broad recognition that treating obesity is cost effective. However, at the same time obesity coverage including medications is required for plans offering insurance to federal employees because it is important to health and cost effective use of care. This conflict of approach reflects political priorities not priorities for health.
Doctors and patients are met with various hurdles to coverage and providers. Effective care involves counseling, medicine, in addition to changes in nutrition and activity. Even among the private insurers that do cover obesity treatment, there is often a heavy bureaucratic burden to care. Requirements for prior authorization and limitations on care can and do provide hurdles for doctors to treat patients effectively and consistently. The panelists emphasized the importance of a reimbursement approach that has incentives to provide value, which is important for all disease areas but particularly for reforms needed in obesity which has little or no reimbursement for certain types of preventive and supportive care delivered by physicians and counselors. Other barriers to care discussed include regulations that don’t allow doctors to take full advantage of telehealth and prescribe medications online, which was a significant and successful component of practice during the pandemic. Changes following the end of the public health emergency have elevated uncertainty in remote care as doctors and patients struggle to navigate unclear rules.
Obesity has a sizeable cost to US government and individuals. If patients received treatment before developing chronic, fatal, and expensive illnesses related to obesity, or had access to care to reduce the negative outcome of those conditions, those costs be reduced. Even 5 percent weight loss improves health and effective treatment can far exceed that. Investment in decreasing obesity among adults has the potential to reduce the prevalence and severity of heart disease, diabetes, and other obesity-related diseases including cancer. By expanding prevention and effective treatment, policymakers can improve individuals productivity and quality of life as well as cost efficacy of the health care system. There will most certainly be a cost, but avoiding care delivery is not a sustainable or humane approach to cost management.
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