Insurance coverage for obesity treatment

Nutrition Research Newsletter, Nov, 2006

The US Preventive Services Task Force now recommends that healthcare professionals offer intensive lifestyle intervention to their obese patients or refer them to other providers. An expert panel convened by the National Heart, Lung, and Blood Institute proposed a treatment algorithm in which lifestyle modification (that is, diet, physical activity, and behavioral therapy) is the cornerstone of treatment for all overweight individuals. Pharmacotherapy and surgery are options for obese and severely obese patients, respectively, particularly in the presence of weight-related health complications.

Thus, there is an increasing need for clinicians to address obesity. One barrier to this may be lack of reimbursement. Anecdotal reports suggest that providers (and patients) are rarely reimbursed for the costs of weight-management services. This situation may change as concerns about obesity increase. For example, recent changes in the federal tax code allow individuals to deduct the cost of behavioral or nutritional counseling, as well as pharmacotherapy and surgery, to treat weight-related illnesses. The Center for Medicare and Medicaid Services also has reversed its previous policy that did not consider obesity to be a disease. This change may facilitate payment for weight management, because private insurers often follow the lead of public payers regarding covered services. Few studies have examined whether health plans reimburse obesity treatment. The objective of this study was to determine the extent of coverage for all major modalities of obesity treatment among health insurance plans in Pennsylvania. The researchers developed a three-page questionnaire concerning coverage for obesity treatment in adults. The questionnaire inquired about all major treatment modalities, including: individual and group dietary counseling; behavioral therapy; physical activity programs; telephone- or Internet-based treatment; meal replacements; commercial programs, including both nonmedical (for example, Weight Watchers) and medically supervised (for example, Optifast) interventions; pharmacotherapy; and bariatric surgery.

In instances in which any coverage was provided, the questionnaire asked about: amount reimbursed or number of visits covered; whether an obesity-related condition was required for reimbursement; and whether there was a cutoff for body mass index (BMI; calculated as kg/[m.sup.2]). Information was also requested on the type of plan, including: health-maintenance organization (HMO); preferred-provider organization (PPO) or point of service (POS); indemnity; or Medicaid. Finally, the questionnaire inquired about the number of persons covered under the most commonly administered benefit plan, and about the position of the person who completed the questionnaire on behalf of the insurer.

A list was obtained from the state Department of Insurance of the 25 health plans that sold insurance in Pennsylvania during 2002. Companies were excluded if they sold less than $1,000 in premiums in Pennsylvania during 2002 or if they sold premiums in 2002 but were not conducting business in Pennsylvania in 2004. Each health plan was contacted through its public relations/corporate communications department and then the questionnaire was forwarded. The first author made all contacts between September and December 2004. In cases in which the questionnaire was partially completed, multiple follow-up attempts were made. Participating plans were assured that their responses would be presented only in aggregate form.

Sixteen plans participated, yielding a response rate of 84% (16 of 19). Of these, four were HMOs, one provided indemnity insurance, five were Medicaid plans, and six were PPO/POS plans. The reported number of persons covered under the plans ranged from 100,000 to 1,160,000, with a mean of 426,000. Thus, the 16 plans that responded accounted for 6,811,000 persons. Assuming that this number includes children, the plans surveyed accounted for 4,960,500 adults, equal to 54% of Pennsylvania's adult population. Individuals from a variety of departments completed the questionnaire for their companies.

Coverage for nonsurgical therapy was inconsistent. For example, 9 of 16 plans (56%) provided their members some coverage for individual dietary counseling. However, only five plans paid for counseling that approached the intensive treatment initially provided in the Diabetes Prevention Program or DPP (that is, 16 or more visits). Other than individual dietary counseling, <50% of plans covered any of the other nonsurgical modalities for weight loss. Some plans did not provide details of coverage. For example, although 7 of 16 plans (44%) reported they reimbursed behavioral therapy, only 4 of these provided information regarding BMI cutoff and requirement for obesity-related conditions. Only one insurer provided any reimbursement for US Food and Drug Administration-approved weight-loss medication. This plan did not specify whether orlistat or sibutramine was covered. In contrast to the varied reimbursement of nonsurgical therapy, all 16 plans provided some coverage for bariatric surgery. Surgery was reimbursed significantly more often than were each of the other treatment modalities. In addition, coverage criteria for surgery appeared to be more consistent. For example, 88% and 100% of plans reported comorbidity requirements and BMI cutoffs, respectively, for surgery, compared with 63% and 29%, respectively, for individual dietary counseling. Several plans reported anecdotally that some adjunct dietary or behavioral counseling was covered for patients who underwent surgery.