Comprehensive Obesity Benefit

Developing a Comprehensive Benefit
for Outcomes-based Obesity Treatment in Adults

 

Obesity is a complex disease with detrimental impacts on the health, wealth, and longevity of Americans. There are evidence-based treatments for people with obesity that mitigate the impacts of the disease and improve health outcomes. The present landscape of obesity care coverage is piecemeal, and providers frequently cite inconsistent and/or inadequate reimbursement for obesity-related services as barriers to delivering appropriate care.

Without guidance on how to operationalize evidence-based behavioral, nutritional, pharmacological, and surgical obesity treatment modalities as health benefits, health insurance plans have taken vastly different approaches in determining what and how obesity treatment services are covered for their members. The lack of consistent coverage is a barrier to needed care for many U.S. adults with obesity. As a first step toward standardizing the provision of obesity care across plans, we have designed a comprehensive benefit for outcomes-based obesity treatment that provides guidance on minimum acceptable coverage for medically-necessary components of obesity care and conditions under which these services and/or items ought to be covered. Development of this comprehensive benefit was informed by input from key stakeholders, including representatives from large employers, health plan administrators, payers, patients, and providers. This document is intended to:

  1. Identify evidence-based obesity treatment modalities that can support clinically-significant weight loss (≥5% reduction in body weight) among persons with obesity
  2. Provide guidance on the appropriate amount, scope, duration, and delivery of obesity-related benefit offerings
  3. Highlight real-world examples from plans that cover obesity treatment modalities
  4. Support efforts to standardize the scope and availability of obesity treatment modalities that are covered across plans / systems.

 

Although we recognize that the design and successful administration of a health benefit is a complicated process, we hope that this tool will inspire employers, payers, and others involved in benefit design and administration to reassess the adequacy of coverage for obesity treatment services in current plan offerings. Where coverage for evidence-based obesity services is absent or limited, we hope that this comprehensive benefit will provide plans with useful guidance for how they can improve obesity care for their members. Where coverage for obesity care is available, we encourage plans to include detailed guidance on what constitutes appropriate provision of obesity-related services in their provider manuals and other relevant communications.

Insurers may choose to administer elements of this obesity benefit in different ways. Although we sought and incorporated feedback from industry experts regarding the feasibility of implementing each component of the comprehensive benefit, this tool does not address expected care costs or specific processes related to benefit administration that likely differ across geographies, systems, and plan types. We limited discussion of reimbursement to suggested cost-sharing arrangements (e.g. copayment), because there were insufficient data to determine which reimbursement mechanisms (e.g. FFS, episodic, capitation) are most likely to optimize provider participation, enrollee engagement, overall benefit usage, and health outcomes in the context of obesity care.

Real-world examples of various reimbursement and care delivery strategies currently in use can be found in the Examples column of each section. The examples are selected from our research on the coverage of obesity treatment across state Medicaid and State Employee Health Insurance programs. (Obesity 2018;26:1834)

We have also not identified particular points at which care should be intensified, because as outlined in our proposed standards of care (Obesity 2019; 27: 1059), the decision to escalate care should be a product of joint decision-making by the provider and patient, informed by prudent clinical judgement and specific needs of the patient. Furthermore, the various provider types mentioned throughout the benefit illustrate current care practices but are not an exhaustive list of the providers who may deliver various components of care. We encourage payers to reimburse various types of providers who can reliably and safely deliver obesity care that achieves the desired treatment outcomes, regardless of their discipline and beyond those specifically mentioned herein.

In the pages that follow, we have outlined what we consider to be the core components of an obesity benefit package that are essential for effective and evidence-based treatment of obesity. We follow this with a section of expanded components. These provide an additional option for the delivery of the core benefits. The expanded components are recommendations based on anecdotal or emerging evidence.

Download the pdf below to read the full report, and visit the Comprehensive Obesity Benefits Checklist page to download a pdf checklist.

 

Download: Developing a Comprehensive Benefit for Outcomes-based Obesity Treatment in Adults (PDF)