ATLANTA – Obesity and its comorbidities loom, threatening to become an expensive national crisis, given that its treatment costs are nearly double that of other chronic diseases, and third party payers so far have failed to invest in its prevention.
"Obese individuals are about 42% more expensive than their normal weight counterparts," accounting for 9% of all medical expenditures, Eric Finkelstein, Ph.D., said at the meeting presented by the Obesity Society and the American Society for Metabolic and Bariatric Surgery.
With close to half the population expected to have a BMI greater or equal to 40 kg/m2 by 2030, even the slightest reversal of trends can save billions, according to Dr. Finkelstein, a health policy research analyst and professor at the Duke-National University of Singapore Global Health Institute (Am. J. Prev. Med. 2012;42:563-70).
‘Bend the curve’
"By 2020, if you could bend even just the cost percentage point by 1 per year, you could have 2.6 million fewer obese adults, and $3.9 billion less in medical expenditures," said Dr. Finkelstein. "By 2030, the numbers go up to 2.9 million fewer obese adults, and $9.5 billion in savings."
The way to bend the curve is through prevention, said Dr. Finkelstein. But, just what constitutes prevention and who should pay for it are not so straightforward.
Although the Affordable Care Act expanded the Centers for Medicare and Medicaid’s coverage of obesity screening and prevention, "there is some debate as to whether the ACA will help this problem," said Dr. Finkelstein.
A trifecta of politics, prejudice, and inconsistent health insurance policies may undermine the legislation’s ability to meet the challenges posed by obesity, according to the symposium presenters.
‘Ounce of prevention, pound of cure’
"Grandma was right. An ounce of prevention equals a pound of cure," noted Dr. Richard Wild, chief medical officer of the CMS in Atlanta.
To that end, he said that under the ACA, there is "more flexibility to [cover prevention] with no cost sharing to patients." CMS obesity screening, prevention, and treatment are largely tied to the U. S. Preventive Services Task Force advisory committee, said Dr. Wild.
A significant percentage of individuals in their mid-20s with class 1 obesity (BMI between 30 and 35 kg/m2) will have BMIs of 40 kg/m2 or greater before they reach their 40s, according to Dr. Finkelstein. By the time they enter their 40s, 63% of males and 78% of women will have an obesity-related comorbidity. Many of those in the 30 to 35 BMI group are likely to continue to a significant weight gain that will make them eligible for bariatric surgery fairly soon," he said.
Early intervention is key to preventing the cost of comorbidities, Dr. Finkelstein said (Surg. Obes. Relat. Dis. 2013;9:547-53).
However, CMS limits Medicare coverage of bariatric surgery to those with a BMI greater than 35 kg/m2, who have at least one related comorbidity and have proven unsuccessful at past attempts to control their weight.
Beyond that, following the USPTF Recommendation Statement (grade B) for screening and treatment of obesity in adults, behavioral intervention is covered when a person has a BMI of 30 kg/m2. If, after 6 months, the person has demonstrated a 3-kg weight loss, continued "face-to-face" weekly visits with a primary care provider of behavioral intervention can continue up to another 6 months.
Politics over patients
Regardless of the point at which intervention is deemed appropriate, access to all available treatments is still not equal, said Dr. John Morton of Stanford (Calif.) University and president elect of ASBMS.
"Let’s make the playing field level," said Dr. Morton. "Everybody should have the same benefits. One Constitution for all of us, one health care benefit for all of us."
Access to bariatric surgery is limited by a number of factors, including the type of health exchange available in the state where a person lives, or whether their employer-backed health plan offers bariatric surgery and if so, at what cost.
"We believe that a big part of any sort of package should definitely be bariatric surgery," said Dr. Morton, citing data on the "tertiary prevention" provided by bariatric surgery. "We hear about statins and all the good they do. If you look at how much mortality they decrease in 5 years, it’s in the single digits. We’re talking about a 40% decrease in mortality in bariatric surgery." said Dr. Morton (N. Engl. J. Med. 2007; 357:753-61).
Noting that as BMI goes up, costs go up, Dr. Morton said that with bariatric surgery, there is a return on investment in a short amount of time. But politics gets in the way of allowing the cost-saving measures of weight reduction surgery to be applied, he said.