13 minute read
Managing Obesity
Employer Weight-Management Programs and Gaps in Strategies
Lindsay C. Speicher, J.D. Project Manager Magellan Method
Nearly 40% of adults in the U.S. suffer from obesity, a rate that continues to rise every year. 1 In 2016, 100.3 million and 80.2 million U.S. residents lived with obesity and overweight, respectively. 2 Patients with obesity, a disease known to be chronic and progressive, have a higher prevalence of serious comorbid conditions — including Type 2 diabetes, hypertension, and cardiovascular disease — than those with normal body mass index (BMI). 3, 4 The significance of the disease is compounded by its economic impact. Obesity accounts for 47.1% of the total cost of chronic diseases nationwide, making it the greatest contributor to the economic burden of chronic disease in the U.S. 2 The estimated annual healthcare costs associated with obesity range from $147 to $210 billion. 5 Weight-related complications associated with obesity and overweight (such as Type 2 diabetes, hypertension, and cardiovascular disease) accounted for $480.7 billion in direct healthcare costs in 2016 alone, with another $1.24 trillion in indirect costs due to lost economic productivity. 2 Projections by health economists indicate that total annual healthcare costs attributable to obesity will be between $860.7 and $956.9 billion by the year 2030. 3 Average medical claims cost per 100 members with obesity ($51,019) is 7.3 times greater than for members without obesity ($7,503). 6 Indirect costs related to obesity include job absenteeism — which can range from $3.38 billion to $6.38 billion annually — and lower productivity, or presenteeism, estimated at $506 per worker with obesity per year. 7, 8 A study published in November 2019 reported that American employees with obesity cost $1,158 more per person per year than employees without obesity, concluding that obesity was associated with high costs among employees across major U.S. industries. 9
Costs associated with lost productivity and absenteeism, in addition to healthcare costs, result in a substantial financial burden for employers, incentivizing many to implement weight-management programs to target obesity in their employee populations. A 2014 poll of large employers revealed that 50% are focusing on weight management, with 20% reporting it would be their top priority in 2015. 10 Employers have a variety of options when it comes to weight-management programs. Some include providing access via employer-provided health insurance plans to lifestyle change agents such as wellness coaches to aid behavior modification; online tracking tools to aid in caloric “accounting”; onsite and/or digital behavior-modification classes through commercial weight-loss providers such as WW or online
weight-control programs; healthy alternative food options onsite; and referrals to weight-management content, including education on nutrition and better healthy dietary choices, through an employer-provided insurer website. 11 These programs largely mirror each other in offerings, focusing on tracking food and calorie intake and behavior modification. However, the returns seen through offering employees weight-management resources are highly variable; few lead to a meaningful improvement in outcomes, largely due to the heterogeneity of the composition of these programs. and progressive nature of obesity is taken into account. Considering that more than 60% of Americans are insured through their employers, this presents a substantial barrier to the healthcare that employees with obesity or overweight need. 14 Overall, lack of coverage by employer-provided health plans for weight loss treatments — such as medical visits for overweight or obesity treatment, behavioral health intervention, anti-obesity pharmacologic treatment, and bariatric surgery — is a major obstacle in effectively targeting and managing obesity and overweight in employee populations. 15 Employers are in an optimal position to improve obesity- and overweight-related management and treatment by increasing access to appropriate care via benefit design. 15
Current Weight-Management Programs
Less than 20% of employers in a 2016 poll agreed that their current strategy promoting healthy weight was effective. 16 Employee engagement is a major challenge cited by nearly 60% of employers, and about half of employers report a rate of only 10% for employee participation in weight-management programs. 10, 17 These low rates of engagement could be attributed to the nature and focus of many employer-provided weight-management programs. One study showed that most employers (more than 80%) provided coverage for bariatric surgery, yet most did not cover weight loss medications. 16 While bariatric surgery is a proven effective treatment of obesity for eligible patients, Magellan Rx explored the structure of employer-provided benefit designs focusing largely on bariatric surgery and the associated gap in care for overweight or obese patients who are not eligible for or not interested in this type of intervention.
Under the Affordable Care Act, employers are permitted to impose penalties and rewards on employees in accordance with specific health-related outcomes, including BMI, blood pressure, and cholesterol; however, only about 5% of large employers utilized this type of program in 2015. 12, 13 An online study conducted in 2013 showed 16% of employees reporting that their respective employers require participation in wellness programs to receive full health benefits. The same study showed that while most employees reported that reduced weight is the most common target with outcomes-based incentives in employer wellness programs, which typically rely on often inaccurate self-reporting to track weight change, most of those employees also reported they did not have access to evidence-based, comprehensive obesity treatment in their employer-provided health plan. 3 Lack of access to evidence-based obesity treatment is significant when the chronic
Benefit structures that focus on bariatric surgery can potentially discourage patients from losing weight or first trying effective treatment alternatives that are much less costly and invasive. In many benefit designs, access to bariatric surgery is conditional upon a specified length — usually three to 12 months — of weight loss and counseling prior to surgery. 16 This additional effort and challenge may present a burden employees are unwilling to overcome, thus precluding them from eligibility. Additionally, many employees may not fully participate for the prescribed length of time in an effort to avoid too much weight loss, which may render them ineligible for bariatric surgery. It is important to note that patients with other diseases are not treated with this strategy; for example, a patient with breast cancer would not be expected to attempt to shrink a tumor on their own prior to being eligible for mastectomy. The patient would initially be offered chemotherapy plus surgery to address the medical condition immediately.
Ultimately, a benefit design that is reliant on surgery precludes employees from preventively addressing obesity. No other chronic disease is treated this way.
The approach to successful employer weight-management programs should incorporate resources for all employees that could benefit from weight loss, not exclusively employees qualifying for bariatric surgery. According to the American Association of Clinical Endocrinologists (AACE) guidelines, behavioral therapy is the cornerstone for treating overweight and obesity, and a structured lifestyle intervention program consisting of a healthy meal plan, physical activity, and behavioral interventions should be available. AACE guidelines make clear that an effective approach to treating overweight and obesity includes a behavior-intervention package executed by a multidisciplinary team that includes dietitians, nurses, educators, physical activity trainers or coaches, and clinical psychologists, and that behavioral health specialists such as psychologists or psychiatrists should participate in the treatment of underlying eating disorders, depression, anxiety, psychoses, or other psychological issues that often attribute to overweight or obesity and can impair the effectiveness of lifestyle intervention programs. 19 Without proper behavioral health intervention, approaches to obesity and overweight treatment or weight-loss programs often prove ineffective long-term. As AACE notes, other people may need pharmacotherapy to assist in carrying out the reduced-calorie diet recommendations. 19
efit design. With this benefit-structured focus, employer-provided or -supported weight-management interventions are likely to be considered only once an employee with obesity has reached a degree at which he or she is considered as a candidate for bariatric surgery. Ultimately, a benefit design that is reliant upon bariatric surgery as the primary weight-loss intervention precludes employees from preventively addressing weight gain, overweight, or obesity with employer-sponsored initiatives. No other chronic disease is treated this way, in which surgery is first.
As such, current employer-provided weight-management offerings usually fail to provide effective promotion of exercise and healthy eating for a reasonable duration; typically, at least one year would be considered an effective duration in order for meaningful results to be achieved. They are likely to limit the opportunity to offer comprehensively designed, tailored interventions to suit each individual’s clinical status. Ideally, weight-management programs should look beyond offering access to bariatric surgery and should provide access to pharmacotherapy options, behavioral health therapy, and other appropriate therapies that are part of a customized treatment plan based on patients’ weight status, history of weight loss, and obesity-related comorbidities.
Gaps in Current Weight-Management Benefit Designs
For most employers, the decision to commit to and offer access to weight-management support programs becomes centered on the decision to provide coverage for bariatric surgical interventions for employees meeting health plan-recommended, employersupported criteria. Weight-management programs that focus on surgical interventions are, as a result, based around medical ben
Due to the complexity of the underlying causes of obesity, management and treatment must be multifaceted. 20 Research shows that adherence to a combination of treatment components can lead to greater weight loss, as well as improvement in related health risks. 21 A National Institute of Health (NIH) report stated: “Effective weight control involves multiple techniques and strategies including dietary therapy, physical activity, behavior therapy, pharmacotherapy, and surgery, as well as combinations of these strategies.” 22 There is a need for a multidisciplinary approach that includes behavioral counseling, support, or education components
in the current weight-management approach taken by employerprovided benefits, whereas a more effective model would constructively coordinate the medical benefit and pharmacy benefit and integrate within the broader employer-sponsored initiative. Lack of integration across the medical and pharmacy benefits and the employer-sponsored programs presents a significant gap.
Evidence of this gap is found when assessing employer-based programs that focus on the prescription drug benefit and access to pharmacologic therapies to support weight-loss efforts. Prescription drug benefit policies governing access to these therapies are not widely available and are typically restrictive; in many cases, pharmacotherapies are not even available as part of the standard pharmacy benefit. When included in the pharmacy benefit drug formulary, weight-loss drugs are likely to require nearly insurmountable prior authorization review and approval processes or have high out-of-pocket costs.
in the design of weight-loss interventions in order to improve longterm success. 20 An example of this type of approach may include physical activity, behavior therapy, and pharmacotherapy, where appropriate, with weight-loss surgery as an option where other treatment options have failed. 22 Additionally, according to the NIH, after six months of initial weight loss, the rate of weight loss tends to plateau due to the physiologic response to weight loss that defends the higher fat mass, thus promoting weight regain again; thus, after targeted weight loss goals are achieved, individuals must continue multifaceted therapy indefinitely for maintenance. 22
A multifaceted weight-management program would likely include a combination of medical benefits, pharmacy benefits, and employer-sponsored programs; managing a program that includes support from various sources can be challenging and would require a unique and targeted benefit design.
Access to obesity-targeting pharmacologic agents would be implemented through pharmacy benefits, while programs such as lifestyle coaching and physical activity initiatives are typically employer-sponsored; behavioral therapy, weight-loss surgery, and office visits fall under medical benefits. A certain disjointedness exists Patients with obesity need access to behavioral health support. Growing evidence suggests that offering bariatric surgery as the primary solution to obesity can be ineffective, as it does not address the behavioral health of employees with obesity. Studies show 20% of patients experience substantial weight regain after surgery. 23 Post-surgery weight regain can often be attributed to addictive behaviors and food urges, as well as lack of selfmonitoring. 24 Studies have shown that unrecognized and untreated eating and psychiatric disorders may lead to post-surgery weight regain in some patients; cognitive behavioral treatment has shown more success in treating these types of disorders than programs without a behavioral or psychological component. 25
The absence of a program structure that results in early or preventive formal involvement with weight-management programs results in gaps in care, despite employers’ best intentions. Currently, few existing programs intervene in a comprehensive or structured manner prior to the point where members have obesity of a degree that warrants surgical intervention. In an effort to address these challenges, Magellan Rx began to explore the necessary steps to develop a comprehensive weight-management program that includes accessible behavior modification, lifestyle modification, nutritional modification, physical activity, pharmacotherapy, and metabolic surgery.
Moving Forward
In the next issue of the Magellan Rx Report, we will explore the paths employers can take to develop and implement these weight-management programs as well as potential challenges they may face.
References
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