|
||||||
|
|
|
|
|||||||||||
|
|||||||||||||
| ||||||||||||||||||||||||||||||||||||
Many health care payers are hesitant to devote resources to reimbursingobesity care because they claim there is a lack of effective treatments. Theysay the evidence simply is not there to justify reimbursing medical, surgical,or other weight-loss options.
"There are not enough proven tools in our armamentarium," saysSusan Pisano, a spokesperson for America's Health Insurance Plans (AHIP), anational insurance association representing about 1,300 members. "Youask us, `Why don't you cover obesity?' We answer, `We want to cover what'sbeen proven to beeffective.'"
Despite a few health care insurers making minor changes to their policieson obesity-related treatments, larger, more substantive policy changes remainelusive.
But at least one insurer, Blue Cross and Blue Shield of North Carolina(BCBSNC), has decided that encouraging doctors to talk with their patientsabout the adverse health effects of excess weight—and reimbursing thedoctors for their time—will pay off. Last October, the North CarolinaBlue Plan announced it would begin this April to pay doctors for theevaluation and treatment of obesity and to fund additional preventive carethat historically has not been covered by insurance.
It claims to be the first insurer to make such a shift since the Centersfor Medicare & Medicaid Services (CMS) last July removed language in itsCoverage Issues Manual stating that obesity in itself couldn't be consideredan illness (DOC News, October 2004). While stopping short ofdeclaring obesity a disease, the CMS decision has been interpreted by many asopening the door to reimbursement for treatment.
The new North Carolina Blue Plan program, called Healthy Lifestyle Choices,will be available for 1.1 million eligible members. It will pay for fourphysician office visits a year for obesity and obesity-related testing. Whenmedically necessary, two weight-loss drugs, sibutramine (Meridia, Abbott) andorlistat (Xenical, Roche), will be covered effective October 1.
BCBSNC will begin credentialing and contracting with licensed registereddietitians early this year in order to reimburse them for providing nutritioncounseling to anyone with a diagnosis of diabetes. Starting October 1 withgroup renewals, that benefit will be extended to include dietitians' servicesin the treatment of obesity, according to BCBSNC spokesperson GayleTuttle.
The insurer will continue to cover bariatric surgery as well for morbidobesity, defined as a body mass index (BMI) greater than 40 or a BMI greaterthan 35 associated with at least one comorbidity. Potential candidates alsomust meet five other criteria detailed in the coverage policy. BCBSNC hasestablished its own Centers of Excellence designation for providers who havesuperior results in bariatric surgery, and pays surgeons at those centers 30%to 50% more, Tuttle says.
DIFFERING APPROACHES TO OBESITY CARE
Other insurers have only tested the waters thus far. Aetna introduced itsweight-management program, called Healthy Body/Healthy Weight, as a pilot inJune 2004, before Medicare's policy-language change and before the unveilingof BCBSNC's program, according to Aetna spokesperson Susan Millerick.
The objective is for Aetna members to achieve greater overall health,Millerick says. The program provides incentives for participation in increasedphysical activity (such as pedometers), discounts to community-basedweight-loss programs, and outreach and support from nurses and weight-losscounselors, as well as coordination with primary-care physicians.
At the conclusion of the program, Aetna will look at before-and-aftermeasurements of BMI, weight, and blood lipid and glucose levels.
Increased payment for physicians managing the plan and assessing thesemeasures is not yet part of the program, Millerick says. This is the importantdistinction.
"At this stage there has been no change to the existing reimbursementpolicies," she says.
As of January 1, Aetna started offering bariatric surgery as a rider ratherthan as standard coverage, except in states where coverage or an offer ofcoverage is mandated.
"The surgery, we felt, was becoming subject to a great deal ofoveruse and a major cost factor that smaller plan sponsors just weren't ableto bear," Millerick says.
Another large insurer, Cigna Corp., will begin to roll out adisease-management program this year targeting not just the obese, but memberswho are at risk of developing weight problems.
The program will identify those with at least three of the factors thatcontribute to metabolic syndrome. Cigna's corporate customers, who will payfor the benefit, will determine how to engage employees and their families inthe program.
Nutritional counseling already is part of some Cigna plans (three visits),as is bariatric surgery, says spokesperson Amy Turkington. She stresses thatit is an employer's decision what kind of coverage to provide itsemployees.
Mary Sellers, a spokesperson for Humana, says that company has not made anychanges to any of the coverage it provides currently. Right now, Humana doesnot cover a weight-loss program. Bariatric surgery is not a covered benefit,nor are fitness center memberships.
"What we have is a lot of flowers blooming right now," saysPisano. "One of them is the large debate about whether or not obesity isa disease."
That is an academic and medical discussion, Pisano explains, and whether ornot obesity is classified as a disease, excess weight and obesity contributeto major health problems that the health system has to pay big bucks totreat.
CUTTING OBESITY-RELATED COSTS
In a study comparing health care spending on obese and normal-weightAmericans between 1987 and 2001, Kenneth E. Thorpe, of Emory University inAtlanta, found that costs incurred among the obese were 37% higher than amongthe normal-weightgroup.1 Per capitaspending for the obese was more than $1,000 higher than spending onnormal-weight people in 2001, his study concludes.
Effective weight-loss interventions must be developed in schools,communities, and workplaces to help contain cost growth, says Thorpe, formerdeputy assistant secretary for health policy in the U.S. Department of Healthand Human Services.
For employers, Thorpe says that obesity is a major issue in terms of lostproductivity, and he calls for the creation of more effective, engagingprograms and for expanding the use of good ones.
Thorpe suggests that Medicare should take the lead in laying out whateffective programs might look like and explicitly list which elements need tobe included in order to make the programs successful.
"You have to tip your hand and help people," Thorpe says.
LuAnn Heinen directs the National Business Group on Health's Institute onthe Costs and Health Effects of Obesity, whose members, mostly self-insuredFortune 500 companies, represent 45 million covered lives. She says many ofthe institute's members are developing the kind of work-site interventionsThorpe mentions, such as changing cafeteria options and physical surroundingsto encourage healthy eating and exercise.
Similarly, the American Diabetes Association recently initiated itsCorporate Health Ambassador program, which supports and recognizes companiesthat commit to educate and motivate their employees to live healthierlives.
Some are covering nutrition counseling, weight-loss drugs, and surgery,while others are involved in research projects to assess the outcomes andcost-effectiveness of these different approaches.
"I'm not sure I see a clear trend," Heinen says."Everyone is very concerned about cost and wants to approach this withthe right blend of prevention and treatment." 
Footnotes
For more information on the ADA's Corporate Health Ambassador program,visitwww.diabetes.org/support-the-cause/corporate-friends/healthambassador.jsp
References
CiteULike 
Del.icio.us 
Digg 
Reddit 
Technorati What's this?
| ||||||||||||||||||||||||||||||||||||
|
||||||
|
| DOC News | Diabetes | Diabetes Care | Clinical Diabetes | Diabetes Spectrum |
