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Obesity coverage

US adult obesity coverage increases but gaps still remain

The proportion of state employee programmes indicating coverage increased by 75% for nutritional counselling (from 24 to 42 states), 64% for pharmacotherapy (from 14 to 23 states) and 23% for bariatric surgery

Coverage for adult obesity care improved substantially in Medicaid and state employee insurance programs since 2009, according to researchers from the Milken Institute School of Public Health, George Washington University, Washington, DC. However, recommended treatment modalities are still not covered in many states.

The paper, ‘Coverage for Obesity Prevention and Treatment Services: Analysis of Medicaid and State Employee Health Insurance Programs’, published in Obesity, sought to examine the changes in coverage for adult obesity treatment services in Medicaid and state employee health insurance programmes - including nutritional counselling, pharmacotherapy and bariatric surgery - changed for non-elderly adults between 2009 and 2017.

The researcher gathered adat from Medicaid and state employee health insurance programmes from all 50 states and the District of Columbia and reviewed for indications of coverage and payment policies specific to evidence‐based treatment modalities for adults with obesity.

Outcomes

The researchers found that coverage for adult obesity treatments increased in both Medicaid and state employee insurance programs between 2009 and 2017, with more improvements in coverage observed among state employee programmes. During this time, Medicaid and state employee programmes were both most likely to cover bariatric surgery and least likely to cover pharmacotherapy for members with obesity. Although, some states decreased coverage for certain obesity treatment modalities during this time.

Specifically, the proportion of state employee programmes indicating coverage increased by 75% for nutritional counselling (from 24 to 42 states), 64% for pharmacotherapy (from 14 to 23 states) and 23% for bariatric surgery (from 35 to 43 states). The proportion of Medicaid programmes indicating coverage increased by 122% for nutritional counselling (from 9 to 20 states) and 9% for bariatric surgery (from 45 to 49 states), with no apparent increase in coverage for pharmacotherapy (16 states).

By 2017, state employee programs were significantly more likely to cover both pharmacotherapy and behavioural/nutritional counselling and Medicaid programs were more likely to cover bariatric surgery (Figure 1). The number of states that appeared to provide comprehensive coverage for obesity treatment modalities for adults increased from 4 to 6 states for Medicaid programmes and from 7 to 19 states for state employee programmes. In 2017, services covered by Medicaid and state employee programs in the same state appeared highest for bariatric surgery (42 states), followed by nutritional consultation (16 states) and pharmacotherapy (7 states).

Figure 1: Evidence of coverage for adult obesity treatment services, 2017. “Covered” indicates strong evidence of possible reimbursement for service when furnished to nonpregnant adults (21+ years). Cross‐hatching indicates states where evidence changed from “not covered/undetermined” (2009 to 2010 plan year [PY09/10]) to “covered” (2016 to 2017 plan year [PY16/17]).

For both Medicaid and state employee programmes, the three most common restrictions included covering services only in certain plans (imposing conservative annual or lifetime caps) and requiring a serious comorbid condition for coverage. For example, annual and lifetime caps on nutritional counselling were stated for 9 Medicaid programmes and 27 state employee programmes. Nine state employee plans provided coverage for pharmacotherapy only in select plans. Twenty‐two Medicaid programmes covered bariatric surgery only with a comorbid condition and six state employee plans covered bariatric surgery only in certain plans. Furthermore, restrictions on bariatric surgery also included temporary provision for a limited number of beneficiaries through a pilot programme and coverage with significant cost sharing - Texas state employees who received surgery were subject to a US$5,000 co-pay with 20% co-insurance.

For Medicaid‐funded bariatric procedures among reported states, the average total cost ranged from US$9,128 in Rhode Island to US$41,440 in Oklahoma and the average length of stay for inpatient procedures was 5.1 days.

Interestingly, the authors noted that the number of Medicaid programmes that explicitly exclude coverage for obesity drugs appears to have increased since 2009, despite FDA approval of three new medications for chronic weight management ie. Contrave, Belviq, and Qsymia.

“These findings emphasise the need for improved coordination and communication in efforts to address obesity among Medicaid and state employee health insurance beneficiaries. In addition to continued improvements in coverage for obesity‐related services, Medicaid and state employee plans should provide clear, consistent guidance on what constitutes appropriate obesity care for adult beneficiaries in all administrative materials,” the researchers concluded. “Although treatment alone will not reverse the obesity epidemic, improved guidance on the availability of covered services may increase provision of medically appropriate obesity care and enable providers and patients to make informed decisions on how to optimise health.”

To access this paper, please click here

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