Obesity Treatment Coverage Rising in US, but Still a Patchwork

Miriam E. Tucker

November 21, 2018

NASHVILLE, Tenn — Coverage for adult obesity treatments has risen considerably in the past decade among US Medicaid and state employee insurance programs, but there is wide state-to-state variation and recommended therapies still aren't covered in many states, new research has found.

Results from the deep-dive investigation were presented recently at Obesity Week 2018 by Nichole Jannah, a research assistant at the Milken Institute School of Public Health, George Washington University, Washington, DC.

The work was selected as one of "five winning papers that provide the latest insights into preventing and treating obesity through innovative research designs" that were included in a special conference symposium and published online November 14 in Obesity.

Jannah and colleagues analyzed Medicaid and state employee health insurance plans in all 50 US states plus the District of Columbia for 2016-2017 and compared the extent of obesity treatment coverage to that found in previously collected data from 2009-2010.

Between the two time points, states generally expanded access to obesity-related care for adult Medicaid and state employee beneficiaries, and most such plans now cover at least one type of obesity treatment.

However, some plans actually dropped coverage for certain services, while the majority of both types of plans still don't offer comprehensive coverage for nutritional counseling, pharmacotherapy, and bariatric surgery, Jannah reported.  

Asked to comment, symposium chair and Obesity associate editor-in-chief Donna H. Ryan, MD, said, "We have a long way to go. There's no consistency...This is why people are going to the health food stores, and turning to unproven and potentially harmful treatments. It's because our hands are tied in good medical practices."    

Physicians Can Move the Needle, Must Become Advocates

But physicians can help move the needle for patients regardless of how they're insured, Jannah told Medscape Medical News in an interview.

"A lot of these changes get made when physicians go to their medical directors and say these things need to be covered, and help compile the evidence," she noted, advising, "advocate for your patients whenever you can, and get your patients to advocate for themselves as well."

Ryan, who is professor emerita at Pennington Biomedical in Baton Rouge, Louisiana, also urged physicians to become advocates. "You can tell your state legislature what you want. They're responsive to the needs of the public. If our state Medicaid and our state employee benefits are not covering what we know are best practices, we need to work on changing that."

Ryan also pointed to proposed legislation, the Treat and Reduce Obesity Act, currently moving through the US Congress. The bill would allow coverage under Medicare for intensive behavioral therapy for obesity, and would also allow coverage under Medicare's prescription drug benefit for drugs used for weight-loss and weight-loss management.

Coverage under Medicare would likely lead to coverage under Medicaid and other payers, Ryan said, noting "that sort of legislation would be game-changing."

The Obesity Action Coalition is on the frontlines of these lobbying efforts, she noted.

In the meantime, Jannah also offered a tip, gleaned from the research: some of the states that say they exclude actually did reimburse, particularly for the obesity medications.

"So there are certainly loopholes in these policies. If physicians go through the prior authorization process and demonstrate medical necessity, then there's potential coverage."  

Wide Variation in Obesity Treatment Coverage Across States, Some Drops

Jannah and colleagues extensively reviewed administrative documents, health plan websites, provider manuals, subscriber handbooks, fee schedules, and drug formularies from Medicaid and state employee health insurance programs in all 50 states and the District of Columbia. For state employee plans, they also analyzed wellness program benefits.

Although both Medicaid and state employee benefit coverage information is in the public domain, it wasn't always easy to access and the language wasn't always clear enough to determine exactly what was, and wasn't, covered.

The investigators attempted to contact the programs in such instances but weren't always successful, so the data were reported as "indicating" coverage status, Jannah explained.

From 2009 to 2017, the proportion of state employee programs indicating coverage increased by 75% for nutritional counseling (from 24 to 42 states), 64% for pharmacotherapy (from 14 to 23 states), and 23% for bariatric surgery (from 35 to 43 states).

Among Medicaid programs, the proportion indicating coverage rose by 122% for nutritional counseling (from nine to 20 states) and 9% for bariatric surgery (from 45 to 49 states), while there was no apparent change in coverage for pharmacotherapy (16 states in both years).

The number of states appearing to provide comprehensive coverage for all three types of treatments increased from four to just six for Medicaid programs and from seven to 19 for employee programs.  

Moreover, coverage for each of the services appeared to have dropped among a handful of states. Notably, the number of Medicaid programs that explicitly exclude coverage for obesity drugs appears to have increased since 2009, despite FDA approval of three new medications for chronic weight management, Jannah pointed out.  

"States may have chosen to cut pharmaceutical coverage to reduce short-term costs or because of misguided concerns over the safety and efficacy of FDA-approved obesity drugs," the authors write in their paper.

And even with coverage, both Medicaid and state employee programs often impose restrictions, such as covering services only in certain plans, imposing annual or lifetime caps, or requiring a serious comorbid condition for coverage.   

In 2016-2017, annual and lifetime caps on nutritional counseling were stated for nine Medicaid programs and 27 state employee programs.

Nine state employee programs provided coverage for pharmacotherapy only in select plans.

Twenty-two Medicaid programs covered bariatric surgery only with a comorbid condition, and six state employee programs covered bariatric surgery only in certain plans.

Among Medicaid plans that included pharmacotherapy coverage, phentermine was the most common, in 33 states, followed by orlistat, in 29. Liraglutide (Saxenda, Novo Nordisk) was at the bottom, covered in only eight state Medicaid programs.

The lack of comprehensive coverage for all types of obesity treatments point to a "problematic treatment gap in which coverage is available for lifestyle interventions (effective for treating mild obesity) and bariatric surgery (effective for treating severe obesity) but not for pharmacologic and medical therapies that are most appropriate for individuals with moderate obesity and a history of unsuccessful weight management efforts," Jannah and colleagues note in their article.   

"Bizarre" Language, Nonevidence-Based Rules, but Some Positive Trends

Language is often a problem. For example, New Hampshire's state employee benefit rules say that nutrition counseling is "limited to three visits per year or unlimited for organic disease, diabetes, or eating disorder," without mentioning obesity specifically.

For pharmacotherapy, some plans use archaic terms such as "anorexics" or "anorectics," Jannah commented, adding, "there was truly bizarre language in some plans. It's not standardized."

Moreover, some of the coverage rules are contrary to evidence-based guidelines, such as New York state employee programs that cover pharmacotherapy for "severe obesity only," Michigan Medicaid's requirement for "at least two failed physician-supervised weight loss attempts" before it will cover weight-loss drugs, and Louisiana Medicaid's rule requiring full-body photographs of patients to gain coverage for bariatric surgery, which Jannah noted is "probably very stigmatizing."

But there were some positive findings as well. A new rule in Wyoming Medicaid now allows registered dieticians to bill Medicaid directly for up to 12 visits per patient per year of nutrition counseling (although it still has to be prescribed by a physician or nurse practitioner).

And in Kentucky, obesity drug coverage may be available to some state employees enrolled in the Why Weight program.

The Kentucky program, Jannah said, represents an increasingly common approach of combining treatment modalities in a weight management program that the state runs and administers. "I think it could be really promising."

After Jannah spoke, Ryan said to her, "I want to thank you for all the painstaking hard work that you and your colleagues did to identify this information and catalog it for us."

"If we want it to change, the first thing we have to do is measure it. We're all grateful to you for doing it."

A compilation of the data is available here.

The research was supported by Novo Nordisk. Jannah has reported no further disclosures. Disclosures for Ryan are listed in the article.

Obesity Week 2018. Presented November 14, 2018.

Obesity. Published online November 14, 2018. Full text

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