Overcoming Stigma Essential to Improving Payer Coverage for Obesity

Only 5% of patients with obesity who lose weight keep it off. Coverage for obesity drugs is improving, but remains uncommon. Only a tiny fraction of the candidates for bariatric surgery have the operation, in part because 70% of physicians won’t give referrals.

All this leaves 93% of those who live with obesity with unmet medical needs, according to Janine V. Kyrillos, MD, an obesity specialist at Thomas Jefferson University Hospital in Philadelphia. Kyrillos led off Friday's session on the needs of those with obesity at Patient-Centered Diabetes Care, presented by The American Journal of Managed Care.

Speakers and panelists explained how many patients with diabetes live with obesity as well, and while these are distinct diseases, their effects overlap. There’s a key difference, however. The stigma associated with obesity—the idea that patients “did this to themselves”—still pervades thinking among many physicians, insurers, and employers, despite the 2013 declaration by the American Medical Association that obesity is a disease.

As Kyrillos explained, the idea that patients can just be told “eat less, exercise more,” fails to capture the many factors, including genetics and environmental causes, that have given rise to the epidemic. Her presentation featured a powerful video with patients sharing how no one should assume they understand a person’s medical history based on what they see.

As conference chairman Robert A. Gabbay, MD, PhD, FACP, chief medical officer of Joslin Diabetes Center said during the panel discussion, no one would deny treatment to a person with type 2 diabetes and say, “Now, go get those blood sugars lower.”

Ted Kyle, RPh, MBA, who founded ConscienHealth after many years in the pharmaceutical industry, said measuring the impact of access to care comes in part by considering the consequences of failing to cover obesity treatment, including medication. “Whether or not healthcare plans cover care for obesity, we are paying for obesity,” he said. “Our ‘sick care’ system does a great job of paying for the result.”

While routine policy exclusions for obesity care remain, Kyle said, reimbursement is better than it was. Besides the AMA declaration, Medicare covers bariatric surgery, and the US Preventive Services Task Force has declared that health plans must cover intensive behavioral counseling for persons with obesity and at least one other cardiovascular risk factor.

There’s also increasing “noise” in medical literature, he said, about evidence that bariatric surgery offers long-term glycemic benefits for persons with type 2 diabetes in addition to its help with weight loss. That helps tilt the cost-benefit analysis scale in favor of surgery for many patients.

And the recent announcement that CMS will pay for the National Diabetes Prevention Program in Medicare will open doors for thousands of new patients to gain access to that evidence-based lifestyle change program, Kyle said. It’s happening because CMS found that Medicare would save money by granting access.

“Bad coverage habits die hard, but they are dying,” he said.

During the panel discussion, Anne Schmidt, MD, associate medical director of Blue Cross Blue Shield of Alabama, said that the transition from fee-for-service to a value-based system will help promote coverage for obesity care, because it will make sense to pay for services with proven outcomes. Evidence from clinical trials in important, Schmidt said, because a key challenge is convincing major employers with self-funded plans that obesity care is worth it.

In Alabama, she said, BCBS is starting with a process measure of asking physicians to record body mass index (BMI) for all adults. Since Kyle pointed out that only 74% of doctors do this nationally, a change by Alabama’s biggest payer in a state with high obesity rates could open many discussions about making changes.

There’s no denying that coverage equals access, said Fatima Cody Stanford, MD, MPH, MPA, a specialist in obesity care at Massachusetts General Hospital. While she agreed that coverage has improved, “We cannot pat ourselves on the back just yet.”

Payer overage is not the only challenge. The way physicians are trained must change, she said, because the bias they carry about obesity does great harm. When a patient with severe obesity comes for a first visit, Stanford said, “I have to have a box of Kleenex.”

A typical patient with a BMI of 40 or higher will have tried multiple diets, including fad programs seen on TV, she said, but “they cry because the doctor told them they just didn’t try hard enough.”

“If one adds up all the money spent on things that don’t work,” Gabbay said, “We’d probably have money for the things that do work.”