Essential Health Benefits and Obesity Treatment Coverage

Life expectancy, smoking prevalence and use of drugs and alcohol have improved over the last three decades

In contrast, obesity prevalence has nearly tripled in the last 50 years Over 2/3 of Americans are overweight and obese 35.7% of Americans are obese It is projected that 42% of the population will suffer from obesity by the year

2030

It is major cause of death attributable to heart disease, cancer, and diabetes according to the Centers for Disease Control and Prevention

Obesity

National Institutes of Health (NIH) recognized obesity as a disease in 1991

American Medical Association (AMA) in 2013 officially recognized obesity as a disease

Governmental agencies recognizing obesity as a disease US Internal Revenue Service (IRS) Centers for Medicare & Medicaid Services (CMS)

Other organizations supporting surgical treatment of obesity American Heart Association (AHA) American College of Cardiology (ACC) American Diabetes Association (ADA) International Diabetes Federation (IDF)

Obesity is a Disease

2000

Obesity Trends* Among U.S. AdultsBRFSS, 1990, 2000, 2010

(*BMI 30, or about 30 lbs. overweight for 5’4” person)

2010

1990

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Ambulatory patient services

Emergency services

Hospitalization

Maternity and newborn care

Mental health and substance abuse disorder services, including behavioral health treatment

Prescription drugs

Rehabilitative and habilitative services and devices

Laboratory services

Preventive and wellness services and chronic disease management

Pediatric services, including oral and vision care

Essential Health Benefits

Each State decides whether the disease of obesity is a covered benefit within the qualifying health plans participating in the State Health Insurance Exchange

27 states and Washington DC do not cover bariatric surgery

Medical treatment for obesity is a covered benefit in only 5 states

Obesity Is Not Covered Under the Essential Health Benefits

Essential Health Benefit Benchmark Plan Coverage of Weight-Related Services

CA

WY

MT

ID

NM

UT

AZ

OR

NV

WA

HI

WI

IA

MN

NE

SD

ND

CO

VT

ME

NH

MARICT

NY

PA

NJ

MD

DEWVVA

SC

GA

FL

AL

NCTN

TX

OK AR

LA

MS

KS MO

ILOH

KY

IN

MI

AK

Current as of 12-10-2012; Coverage may have changed since this printing

Does not cover bariatric surgery nor weight loss programs

Covers weight loss programs but does not cover bariatric surgery

Covers bariatric surgery but does not cover weight loss programs

Covers bariatric surgery and weight loss programs

DC

Source: Center for Consumer Information and Insurance Oversight summary of EHB benchmark plans based on 2012 benefits – STOP Obesity Alliance, Weight and the States Policy Research Bulletin, December 2012.(States that have not selected an EHB benchmark plan defaulting to the largest small-group employer plan in the state.)

Excess weight is responsible for 2.8 million deaths worldwide annually

Obesity accounts for 21% of national health spending

Obesity discrimination plays an important role in lower income and production

9% lower income

Economics of Obesity

Obese individuals have 42% higher annual healthcare costs 77% higher prescription costs (as high as 105%) 37% higher primary care costs

Obesity raises annual medical costs per obese individual by $2,741 (in 2005 dollars)

Obesity increases lifetime medical costs by 50%

Economics of Obesity

Productivity Costs Obese individuals compared to healthy weight individuals

have been shown to have 3.73 additional days lost annually 1.23 times higher absenteeism rate 194% more likely to use paid time off Greater lost productive time while present at work

Bariatric surgery provides immediate benefit by decreasing lost work time and disability

Treatment costs associated with bariatric surgery were relatively small compared to economic losses of not treating obesity

Economics of Obesity

24 million Americans have Type 2 Diabetes

41% increase in the total costs of treating diabetes was noted from 2007 to 2012

$174 billion to $245 billion

Economics of Obesity and Type 2 Diabetes

Durable weight loss 106 pound mean weight loss after 16 years

Remission of Type-2 diabetes (83%)

Reduction in mortality from diabetes by 78%

Bariatric Surgery Outcomes

Resolution of Obesity-related Medical Problems

High blood pressure 63.3% Sleep apnea 68.9% High cholesterol 61.4% Asthma 66% Gastroesophageal reflux 87.6% Arthritis of weight-bearing joints 61.4%

Bariatric Surgery Outcomes

Lifetime costs to medically treat a patient with Type-2 diabetes is approximately $300,000

compared to approximately $25,000 for bariatric surgery

Total health care costs Increased 9.7% in the first year after surgery, but Decreased by 34.2% and 70.5% in years 2 and 3 after surgery

Life expectancy is improved in bariatric surgery patients when compared to medically managed patients

Several studies show increased short-term medical costs are increased, but at an acceptable level of cost effectiveness (given that the guideline for cost-effectiveness in the United States is less than $50,000/quality-adjusted life years)

$21,973/quality-adjusted life years (QALY) $7,000-$9,000/QALY for gastric bypass surgery $11,000-$13,000/QALY for gastric banding surgery

Bariatric Surgery for Type-2 Diabetes

Compared 3651 bariatric surgery patients and 3651 matched surgery-eligible control subjects

Assessed total healthcare costs 6 month prior to surgery and up to 5 years after surgery

Cost savings began accruing as early as 3 months after surgery

Total surgery costs were fully recovered after 49 months for open procedures after 25 months for laparoscopic procedures

Cost Effectiveness Analysis

Mortality rate is 4.5% per year without surgery compared to 1% per year after surgery

Only 1% of the eligible population is treated through bariatric surgery

About 25% of patients considering surgery are denied approval for surgery at least three times before obtaining approval

By then, 60% will report worsening health problems

Three of every 100 patients denied surgery will lose their lives in the next year due to deaths that could have otherwise have been prevented with surgery

Cost of Human Lives

In-Hospital mortality rate for bariatric surgery is now 0.1 %

Gallbladder surgery mortality 0.52 %

Hip replacement surgery mortality 0.93%

Bariatric Surgery is SAFE!

Not cost effective In the long-term, surgery is less costly

Patients in your state are being denied treatment that is widely available to approximately 45% of Americans

Consider that therapy for patients with other chronic diseases are not denied coverage treatments are far more expensive and less effective in

terms of remission of disease and decreasing disability and increasing productivity Cancer treatments (medical and surgical) Heart surgery

Denying Bariatric Surgery

Obesity treatment coverage should be equitable for all Americans, including citizens who are beneficiaries covered through your State’s Health Insurance Exchange