Dietary risk is now the leading risk factor related to death in the U.S., according to a seminal study in JAMA. In fact, dietary risk, high body mass index (BMI), and low physical activity are all top 10 mortality risk factors. Given this, one would think that health insurers would identify this issue as a high priority, and yet we hear comparatively little from them about obesity prevention and treatment efforts. Why?
Understanding the Weight of the Problem
More than 2 in 5 Americans are obese (estimated BMI ≥30) and about 1 in 11 are severely obese (BMI ≥40). As noted in a recent Bipartisan Policy Center (BPC) report, “there were as many adults with obesity in the U.S. in 2018 as there were total residents in the five most populous states combined (California, Texas, Florida, New York, and Pennsylvania), and more severely obese adults than there were adults in the state of Texas.”
Obesity-related conditions include heart disease, stroke, type 2 diabetes, and certain types of cancer, all of which are among the leading causes of preventable death. Obesity is also estimated to be responsible for $248 billion in annual medical expenditures and estimated to incur $524 billion in lifetime Medicare expenditures for current beneficiaries with obesity.
Despite the prevalence of obesity-related conditions, public and private insurers have been inconsistent in their coverage of evidence-based interventions. A recent study in Obesity found that while coverage has improved in Medicaid and state employee insurance programs over the last decade, many programs still fail to cover nutritional counseling, pharmacotherapy, or bariatric surgery.
While coverage exists for some Medicare patients — for example, for intensive behavioral counseling for beneficiaries with a BMI ≥30 — fewer than 1% of qualified beneficiaries receive this intervention. Furthermore, there is a statutory prohibition on Medicare coverage of pharmacologic treatments, predating the enactment of Medicare Part D in 2003, that characterizes weight loss drugs as cosmetic. Of course, in 2022, it is well established in the medical community that obesity is a chronic disease, and there are FDA-approved medications available for treatment.
Making Healthy Weight a Priority
One barrier to addressing obesity is the fact that individuals tend to change jobs every 4 years, creating frequent churn as those with employer-sponsored health insurance coverage switch their health plans. As a result, any investment in obesity prevention is likely to be recouped by another entity, which limits the incentives for insurers to invest and further fuels the obesity epidemic at older ages. One solution is to establish regional multi-payor initiatives where the dominant insurers in a specific geographic area agree to similar coverage of evidence-based obesity interventions. The My Healthy Weight Pledge, though not regional in nature, was one attempt to do this and could serve as a template for future efforts.
Congress should also expand access to evidence-based obesity interventions for Medicare beneficiaries. This includes allowing registered dietitians to bill Medicare for delivery of intensive behavioral therapy (IBT) as well as expanding the settings in which IBT may be provided. Congress should also remove the statutory prohibition on Medicare Part D coverage for FDA-approved pharmacologic treatments. This would allow CMS to assess whether coverage of treatments is reasonable and necessary for the Medicare population.
In addition, given that quality metrics are the currency of value-based healthcare transformation, private and public insurers should adopt measures to address the prevalence of obesity and change in BMI over reasonable periods of time. As noted previously, to prevent adverse selection by insurers, risk-adjustment strategies could be used in addition to assessing relative improvements over time. This would catalyze the clinical-community linkages needed to address obesity. These metrics should be used by the full breadth of CMS programs, including accountable care organizations, the Medicare Advantage Star Rating system, and the Core Set of Adult Health Care Quality Measures for Medicaid.
While these ideas can incentivize insurers and healthcare professionals to engage in evidence-based obesity care, more professional training and best practices for engaging patients are needed. Previously, BPC worked with 20 leading health organizations representing a dozen health professions to issue the Provider Competencies for the Prevention and Management of Obesity to ensure that all healthcare providers are adequately trained to provide obesity care. Ensuring that patients know about available interventions will not only help to address obesity, but also will increase understanding and reduce stigma.
Mitigating obesity may not be the easiest priority for insurers, but it might be the most important. It’s time that public and private health insurers tackle the leading risk factor of U.S. mortality: It’s in their interest and ours.
Anand Parekh, MD, MPH, is chief medical advisor at the Bipartisan Policy Center and formerly served as deputy assistant secretary of health at the Department of Health and Human Services.
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