Transcript Essential Health Benefits Toolkit

Essential Health Benefits and
Obesity Treatment Coverage
Obesity
 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 is a Disease
 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 Trends* Among U.S. Adults
BRFSS, 1990, 2000, 2010
(*BMI 30, or about 30 lbs. overweight for 5’4” person)
2000
1990
2010
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Essential Health Benefits
 Ambulatory patient services
 Emergency services
 Prescription drugs
 Rehabilitative and habilitative
services and devices
 Hospitalization
 Laboratory services
 Maternity and newborn care
 Preventive and wellness services
and chronic disease management
 Mental health and substance abuse
 Pediatric services, including oral
disorder services, including
and vision care
behavioral health treatment
Obesity Is Not Covered Under the
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
Essential Health Benefit Benchmark Plan Coverage of
Weight-Related Services
AK
WA
OR
MT
ME
ND
ID
MN
WI
SD
WY
UT
CO
KS
Does not cover bariatric surgery nor weight
loss programs
NJ
WV
KY
DE
VA
MD
NC
TN
AR
NM
DC
SC
MS
TX
OH
IN
MO
OK
HI
RI
CT
PA
IL
CA
AZ
MI
IA
NE
NV
NH
VT
MA
NY
AL
GA
LA
FL
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
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.)
Current as of 12-10-2012; Coverage may have changed since this printing
Economics of Obesity
 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 and
Type 2 Diabetes
 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
Bariatric Surgery Outcomes
 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
Sleep apnea
High cholesterol
Asthma
Gastroesophageal reflux
Arthritis of weight-bearing joints
63.3%
68.9%
61.4%
66%
87.6%
61.4%
Bariatric Surgery for Type-2 Diabetes


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
Cost Effectiveness Analysis
 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 of Human Lives
 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
Bariatric Surgery is SAFE!
 In-Hospital mortality rate for bariatric surgery is now
0.1 %
 Gallbladder surgery mortality 0.52 %
 Hip replacement surgery mortality 0.93%
Denying Bariatric Surgery
 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
 Obesity treatment coverage should be equitable for
all Americans, including citizens who are beneficiaries
covered through your State’s Health Insurance
Exchange