National Group Urges HHS to Classify Obesity Counseling and Treatment as Essential Health Benefits

Shape Up America! Wants to Extend Medicare Coverage for Obesity Treatment to All Obese Americans

WASHINGTON, Dec. 14, 2011 /PRNewswire-USNewswire/ -- As the Department of Health and Human Services (HHS) considers what health benefits must be covered by new state insurance plans operating under the Affordable Care Act, one of the nation's leading groups on healthy weight for life is encouraging HHS to follow the lead of its agency, the Centers for Medicare and Medicaid Services (CMS), by extending Medicare coverage for obesity screenings and physician-based counseling to the rest of the obese population.

Calling CMS's November 29 coverage decision a "major step forward" in the nation's fight against obesity, Shape Up America! is now advocating that HHS extend existing CMS policies to the estimated 70 million Americans who are obese (those with a Body Mass Index of 30 and above).  Besides lauding the CMS decision to cover counseling for obese adults on Medicare, the organization is further pressing HHS to follow CMS's earlier national coverage policy, which pays for surgical treatment for the severely obese (those with a BMI of 40 or higher or with a BMI of 35 and above if they have a chronic medical condition such as diabetes or high blood pressure). Because of the high prevalence of obesity and its correlation to many chronic diseases, this disorder is responsible for more health care expenditures than any other medical condition.

"As HHS defines the essential health benefits private insurance plans must cover under the Affordable Care Act, the agency should not overlook the pressing issue of combating obesity in America," said Barbara J. Moore, Ph.D., president and CEO of Shape Up America! "Including comprehensive obesity counseling and evidence-based treatment regimens is justified to improve the health outcomes and reduce the costs associated with chronic diseases associated with obesity. Moreover, CMS's coverage policies establish a solid foundation for HHS to act."

According to Shape Up America!, there is an urgent need for public policy to address the difficult challenges affecting the more than 15 million adults and 2.7 million children who are severely obese and face a greatly increased risk of diabetes, high blood pressure, high cholesterol, asthma and osteoarthritis. Now comprising approximately 5.7 percent of the U.S. population, the severely obese are 2-3 times more likely to die of preventable disease than persons at a healthy weight.  In fact, life expectancy for those with severe obesity can be reduced by as much as 8 to 12 years.

Because cost effectiveness is a major factor influencing HHS decision-making, Shape Up America! laid out the cost benefits of extending CMS policies to all obese Americans.  Addressing the strong correlation between obesity and chronic disease, the organization cited findings from a Congressional Budget Office (CBO) issue brief, which reported that between 1987 and 2007 the difference in spending on obese individuals compared to those of normal weight increased from 8 percent to 38 percent – or almost a five-fold increase.  Based on these findings, Shape Up America! cautioned that unless HHS intercedes to give obese Americans greater access to comprehensive obesity counseling and evidence-based treatment regimens, healthcare expenditures attributed to obesity will only increase from the estimated $198 billion a year currently spent on the direct and indirect costs of obesity to as much as $344 billion by 2018, or 21% of direct health care spending.

When it comes to the severely obese, Shape Up America! also challenged the conventional wisdom that adults needing to lose 100 pounds or more can achieve lasting weight loss through methods that are effective for the moderately obese -- diet, exercise, pharmacotherapy and behavior modification. Although these interventions work in some significantly overweight individuals, controlled studies show these efforts alone are usually ineffective for producing durable weight loss in severely obese patients.  In contrast, weight-loss surgery followed by appropriate lifelong medical care produces clinically significant, lasting weight reduction in the majority of severely obese patients and improves most, if not all, comorbidities of obesity.

Studies also demonstrate a significant reduction in the risk of death from obesity-related chronic diseases in patients who had surgery, including a 92 percent drop in death from diabetes, a 60 percent reduction in cancer deaths and a 56 percent reduction in deaths from cardiovascular disease.

Reinforcing these research findings, Shape Up America! pointed to a number of international studies that  have measured the amount of time it takes for insurers to recoup the direct medical costs of bariatric surgery to treat obesity-related disease. Outside the U.S., where severe obesity prevalence is increasing rapidly in all developed countries, economic analyses demonstrate the cost savings of surgical intervention for the severely obese. This includes one government-sponsored economic analysis, which showed that bariatric surgery is cost-effective and would realize a net savings for the U.K. health care system in less than 2 years.  

Among the research conducted in the U.S. is a large study comparing the health claims data for more than 7,000 patients treated with laparoscopic surgery with a matched control group of severely obese individuals, which found that the surgical treatment paid for itself in 0-2 years for patients with diabetes and within 4 years for the rest of the surgery-eligible population. Moreover, the study found that even after including the costs of follow-up care or adverse events, there was a 23 percent reduction in the average annual costs for diabetes medications (from $678 annually to $550 annually) in the 5 years after surgery.

Along with this body of evidence, Shape Up America! offered another important argument for including the treatment of severe obesity as an essential health benefit: ample precedent already exists through both government policy and the decisions of the medical community.  Currently, CMS has implemented a national coverage policy for weight-loss surgery to help reduce significant health risks associated with severe obesity and a significant number of commercial payers now recognize the health savings associated with this treatment. In addition, a number of prominent medical societies have issued consensus statements or revised their clinical practice guidelines to recommend surgical intervention, including the American Academy for Clinical Endocrinologists, American Diabetes Association and the American Heart Association.

"When it comes to the cost effectiveness of specific healthcare services, there is ample evidence to include the treatment of severe obesity both to avert disease, suffering and death and to control healthcare costs," said Dr. Moore. "Policies that expand obesity counseling for the moderately obese and cover surgical interventions for those with severe obesity are urgently needed to help stem the obesity epidemic in America."

About Shape Up America!
Shape Up America! was founded in 1994 by former U.S. Surgeon General C. Everett Koop to raise awareness of obesity as a health issue and to provide responsible information on weight management to the public and to health care professionals. The organization maintains an award winning website – www.shapeup.org – accessed by more than 100,000 visitors each month.

SOURCE Shape Up America!