1. Inform health care providers and administrators of the tremendous burden of overweight and obesity on the health care system in terms of mortality, morbidity and cost.
2. Inform and educate the health care community about the importance of healthy eating, consistent with the Dietary Guidelines for Americans, and physical activity and fitness for the promotion of health.
3. Educate health care providers and administrators to identify and reduce the barriers involving patient's lack of access to effective nutrition and physical activity interventions.
4. Inform and educate the health care community about assessment of weight status and the risk of inappropriate weight change.
5. Educate health care providers on effective ways to promote and support breastfeeding.
6. Review and evaluate the reimbursement policies of public and private health insurance providers regarding overweight and obesity prevention and treatment efforts.

It is time for NCQA to respond to the Surgeon General's Call to Action and to take the leadership in bringing the managed care industry to address the epidemic of obesity in the United States. Obesity is at least as important as diabetes, smoking, cholesterol, high blood pressure, asthma and heart disease. Every day we are reminded of the seriousness of this epidemic. Just recently a report was presented at the American College of Cardiology of a study of 575 obese otherwise healthy young women which found that 25% had abnormally large hearts and 20% were diagnosed with left ventricular hypertrophy. Left ventricular hypertrophy leads to a weakening of the heart muscle, undermining its ability to efficiently pump blood through the body, a precursor to congestive heart failure, a lethal problem.

Yet the managed care industry has not acknowledged the powerful role of obesity in health as it has these other conditions. It is time to change this pattern and NCQA leadership is critical. Employers and taxpayers now pay for the heart disease, diabetes, stroke and other conditions caused by obesity which can be reduced or eliminated by obesity treatment. Addressing obesity is essential to the integrity of a national system of accreditation of managed care providers.

Our comments are applicable to managed care organizations (MCOs), Medicare and Medicaid.

2. Background

Obesity is a serious disease which is well established scientifically as an independent cause of extensive mortality and morbidity. Studies have confirmed an estimated 300,000 premature deaths a year from obesity. Obesity's impact on health is as great as that from smoking, poverty and problem drinking. The diseases caused by obesity, including heart disease, type 2 diabetes, several cancers, osteoarthritis of the knee and hip, sleep apnea, hypertension, high cholesterol, and stroke, are among the most serious and costly in society. Over thirty health conditions are being research for their association with obesity.

Obesity has been recognized as a major health problem by the Surgeon General of the United States, the World Health Organization, the National Institutes of Health and the Centers for Disease Control and Prevention.

In addition, obesity carries psychosocial problems including extensive discrimination in education, employment and health care.

According to the NHANES 1999 data, 34% of U.S. adults aged 20 to 74 years are overweight and an additional 27% are obese in contrast to the late 1970s when 32% of adults were overweight and 15% obese. 13% of children aged 6 to 11 years and 14% of adolescent aged 12 to 19 are overweight. During the past two decades, the percentage of children who are overweight has nearly doubled and the percentage of adolescents who are overweight has almost tripled. Increases in the prevalence of obesity have occurred in both genders, across all races, ethnic groups and age groups. However, racial, ethnic and gender disparities do exist in many segments of the population.

Traditionally, the managed care industry has been a leader in pregnancy and well baby care. Young women who are increasingly overweight and obese are entering their child-bearing years. A new report from the March of Dimes Task Force on Nutrition and Optimal Human Development states that each year in the United States, women's excess weight before pregnancy contributes to the premature births of more than 450,000 babies. The rate of premature births has increase by 23% since the early 1980s. Currently, over 40% of non-pregnant U.S. women ages 15 to 49 are overweight or obese. Overweight before pregnancy increases risks of gestational diabetes and hypertension of pregnancy (pre-eclampsia and eclampsia) and require hospitalizations before normal delivery time. Women with obesity are more likely to require Caesarian sections and longer recovery time than vaginal births. With increasing weight, the risk of stillborn or early infant death increases. Babies of overweight mothers are 30 to 40% more likely to experience birth defects, including heart malformations, abdominal wall defects, intestinal abnormalities and neural tube defects like spina bifida. Folic acid supplements appear to be less effective in women who are overweight than in other women.

3. High Costs are Associated with Obesity

A recent RAND study (Sturm) found that obesity has roughly the same association with chronic health condition as aging 30 years, far exceeding the associations of smoking or problem drinking with chronic health conditions. Obesity is associated with a 36% increase in inpatient and outpatient expenditures and a 77% increase in medications, compared to a 21% increase in inpatient and outpatient expenditures and 28% increase in medications for current smoker and smaller effects for problem drinking.

The American Obesity Association commissioned a cost study in 1999 by the Lewin Group, a respected health economics consulting firm. The Lewin Group examined the costs of some fifteen conditions causally related to obesity. They included: arthritis, breast cancer, heart disease, colorectal cancer, type 2 diabetes, endometrial cancer, end-stage renal disease, gallbladder disease, hypertension, liver disease, low back pain, renal cell cancer, obstructive sleep apnea, stroke and urinary incontinence. Utilizing the National Health Interview Survey in 1995 and the NHANES III database, they established prevalence rates of each comorbid condition. For each condition, the percentage of the cost of each disease was determined through the scientific literature or professional associations and were computed according to the percent of the costs attributed to obesity. This method established the direct health care costs of obesity at $102.2 billion in 1999. This study did not examine indirect costs. It should be noted that the study relied on published data on the costs of the specific comorbid diseases. There was probably some amount of double counting in the figure which could not be adjusted.

The Lewin study confirmed other studies in finding a direct correlation between increases in Body Mass Index (BMI) and increases in the prevalence of comorbid conditions, especially type 2 diabetes, hypertension, heart disease, stroke and arthritis.

In 1998, Wolf and Colditz concluded that the total direct costs for attributable to obesity were $51.64 billion in 1994. However, Wolf and Colditz had fewer comorbid conditions with economic data than were available to the Lewin Group.

Wolf and Colditz estimated $47.56 billion in indirect costs in 1994 which included lost productivity and restricted activity days. Their study concluded obesity was responsible for about 5.7% of national health expenditures. Lewin Group figures would equate to about 9.8% of national health expenditures. Heithoff found that health care expenditures among both underweight and overweight individuals increased in relation to ideal weight.

David Thompson reported that the cost of obesity to U.S. business in 1994 was $12.7 billion, including $2.6 billion as a result of mild obesity and $10.1 due to moderate to severe obesity. Health insurance expenditures constituted $7.7 billion of the total among, representing 43% of all spending by U.S. business on coronary heart disease, hypertension, type 2 diabetes, hypercholesterolemia, stroke, gallbladder disease, osteoarthritis of the knee and endometrial cancer. Obesity-attributable business expenditures on paid sick leave, life insurance and disability insurance amounted to $2.4 billion, $1.8 billion and $800 million respectively.

Given methodological differences, these findings are consistent with numerous other studies. (See, Kort, Hughes and Seidell.)

In a study of members of a large HMO, Quesenberry found an association between BMI and additional annual inpatient days and costs of outpatients visits, costs of outpatient pharmacy and laboratory and total costs. Tucker found that obese employees were more than 1.74 as likely to experience high-level absenteeism and 1.61 times more moderate absenteeism than were lean employees. This finding is similar to that of Burton and colleagues.

Burton et al found that as Body Mass Index (BMI) increased so do the number of sick days, medical claims and health care costs. The mean annual health care costs were $2,274 for individuals above a BMI of 27 and $1,499 for workers below that level. They suggest, "Employers may benefit from helping employees achieve a healthier weight."

4. Current Obesity Treatment Recommendations

Weight loss interventions work and can result in the reduction of many of the comorbid diseases associated with obesity. Weight loss involves more than a choice of foods. Research indicates that effective weight loss interventions, including surgery and pharmacology use behavior modification to promote healthier lifestyle.

The recent concluded Diabetes Prevention Program (DPP) which clearly demonstrated that significant reductions in the risk of developing type 2 diabetes among persons with obesity with impaired glucose tolerance. The reductions in risk was greatest in lifestyle modifications although pharmacological intervention with metformin also showed reductions in risk as well.

In 1998, the National Institutes of Health issued comprehensive Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The National Institutes of Health recommended treating overweight and obesity based "not only on evidence that relates obesity to increased mortality but also on RCT (randomized clinical trials) evidence that weight loss reduces risk factors for disease. Thus weight loss not only may help control diseases worsened by obesity, it may also help decrease the likelihood of developing these diseases."

Based on exhaustive reviews of numerous studies, the NIH made several recommendations including the following:

A study of primary care physician practices in Michigan (Noel) confirmed that "a modest weight loss of 15 pounds per person would markedly reduce the prevalence of overweight in our patients from 53% to 37 and from 28% to 18%, respectively."

In 1991, the National Institutes of Health published a Consensus Statement on surgery for the treatment of morbid obesity. It cited studies showing that following bariatric surgery, most patients lost weight rapidly and continued to do so for 18 to 24 months. Patients may lose up to 50% of their excess weight in the first six months and 77% of excess weight in one year. Patient were able to maintain 50 to 60% of their weight loss 10 to 14 years after surgery.

In 1998, the National Institutes of Health Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults makes the following recommendation:

"Surgical intervention is an option for carefully selected patients with clinically severe obesity (a BMI >40 or >35 with comorbid conditions) when less invasive methods of weight loss have failed and the patient at high risk for obesity-related morbidity and mortality."

This recommendation was based on a review of 14 randomized clinical trials of different surgical interventions. Weight loss ranged from 110 pounds to as much as 200 pounds over a period of six months to one year. Comorbidity factors associated with weight loss showed improvement after surgery. One study showed that medical illnesses either improved (47%) or resolved (43%) in all but four patient (9%) and these four had unsatisfactory weight loss. The Adelaide Study showed that 60% of the patients who initially had obesity-related comorbidity were free of medication for these comorbidities 3 years after surgery.

An article in Obesity Surgery in June of 2000 by Wittgrove and Clark show that 96% of certain obesity-related health conditions (back pain, sleep apnea, high blood pressure, diabetes and depression) were improved with surgery.

5. Cost Savings from Treatment

As with many areas of health care, the precise cost savings attributable to an intervention have not been well studied.

However, an encouraging model does exist. Oster et al have developed a model of the relationship between body mass index and the risks and costs of 5 obesity-related diseases. They then calculated the lifetime health and economic benefits of a sustained 10% reduction in body weight from men and women, aged 35 to 64 with mild, moderate and severe obesity. They found that a sustained 10% weight reduction would:

• reduce the expected number of years of life with hypertension by 1.2 to 2.9 years, with hypercholesterolemia by 0.3 to 0.8 year, and with type II diabetes by 0.5 to 1.7 year,
• reduce the expected lifetime incidence of coronary heart disease by 12 to 38 cases per 1000,
• reduce stroke by 1 to 13 cases per 1,000,
• increase life expectancy by 2 to 7 months, and,
• reduce expected lifetime medical care costs of these five diseases by $2,200 to $5,300.

Narbro et al studied patients who had gastric bypass surgery in Sweden. They found that before surgery, the number of sick days plus disability pension were similar between controls and subjects. After surgery, the patients had more sick days in the first year but fewer days of sick leave in years 2 and 3. During the fourth year, the surgical group had fewer sick days. They concluded that surgical treatment of obesity results in a reduction of sick leave and disability pension compared to controls.

Weight losses as small as 10% are associated with substantially reduced health care costs, reduced incidence of obesity-related comorbid conditions and increased lifetime expectancy. (Goldstein)

Gastric bypass surgery has demonstrated even more impressive effects, with lower costs and greater long-term weight loss maintenance in comparison to low-calorie diets and behavior modification as well as significant reductions in BMI, incidence of hypertension, hyperinsulinemia, hypertriglyceridemia, and hypo-high density lipoprotein cholesterolemia, and sick days from work compared with matched controls. (Martin)

In 1999 a retrospective study of the effects of weight loss on health care costs was published. A team from Group Health Cooperative of Puget Sound examined utilization and cost for 60 of its HMOs enrollees as compared to a group of 45 equally overweight enrollees. Both groups had similar BMI of about 39 and an average weight of 241 lbs. After a Very Low Calorie Diet for three months, treatment subjects lost about 11% of their weight to a BMI of 35, maintained that weight for 2 years and gradually regained over 7 years to close to their starting weights. In the first year, health care costs for the treatment group were $317 greater than controls. Thereafter, costs were significantly lower in the treatment group compared to controls in each year. Even including the first year, the average annual difference between the treated and untreated groups was $1,648 ($3,217 versus $4,865) or a total savings over 7 years of $11,536 per person. The average annual costs of health care for the controls was 50% greater than those in treatment, even though most of the weight was regained. (Berkson)

6. Recommedations

The American Obesity Association urges the following changes:

1. MCOs should capture height and weight on their members and convert to Body Mass Index (BMI).

It appears based on our understanding that most MCOs do not take height data on their members even if they take weight. Without both height and weight, MCOs cannot do the computation for the Body Mass Index (BMI). BMI is the international standard for determining obesity and overweight. While the BMI is not perfect measure and while other measures do exist, the BMI is the most widely used in the medical and scientific literature. Without BMI information, MCOs cannot compare their members' health status with the scientific literature or meaningfully track health care outcomes.

2. MCOs need to counsel overweight and obese members on appropriate weight maintenance and weight loss techniques.
3. MCOs need to counsel all patients on value of physical activity, especially in regard to weight loss, weight maintenance, cardiovascular and respiratory risk factors.
4. Adolescents and children who are overweight should be tested for impaired glucose tolerance and monitored for type 2 diabetes and heart disease.
5. MCOs quality improvement processes need to implement obesity treatment vis a vis the National Institutes of Health Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweigh and Obesity in Adults.
6. Women members of childbearing age should to be counseled about the risks of weight gain during pregnancy.
7. Reviews of claims for obesity services must be made by specialists in the fields.
8. Program Operations Reviews

Quality Improvement Program
Element A:

Add: The QI Committee established the plan's policies on obesity treatment and prevention

9. Health Management Systems

Identify Chronic Conditions:

The organization identifies three chronic conditions, one of which must be obesity.

Identifying Eligible Members:

Eligible Members are those diagnosed with or at risk condition, including persons with obesity.

Types of data should include BMI.

Measuring Effectiveness:

Organization should track two population based performance measures, one of which must be obesity.

10. Clinical Practice Guidelines

Standard:

The organization should be required to review, adopt and disseminate the National Institutes of Health 1998, Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults.

11. Appendix XX

HEDIS and CHAPS Measures:

Add to the list:

Obesity Prevention and Treatment Counseling

Counseling on Physical Activity

Comprehensive Obesity Treatment

Counseling Pregnant Women on Weight Issues

12. Utilization Management: Appropriate Professionals

Element D:

Add to Standard:

In the case of claims, relating to obesity, the appropriate practitioner must be a specialist in obesity management.

13. Utilization Management: Appropriate Handling of Appeals

Add to Standard:

The organization assures that reviewers are free of stereotyping attitudes as, for example, in the case of persons with obesity.

14. Utilization Management: Procedures for Pharmaceutical Management

Element A:

Add to #3:

Considers pharmaceuticals for the treatment of obesity in the same manner as products for any disease.

15. Preventive Health 2: Distribution of Guidelines to Practitioners

Standard:

Add: The organization distributes the 1998 National Institutes of Health Clinical Guidelines on the Identification, Evaluation, And Treatment of Overweight and Obesity In Adults.

16. Medical Assistance With Smoking Cessation

This section fails to address the relationship of smoking and weight. Questions should be developed which can identify the extent to which members smoke as a weight management device so that appropriate information and counseling may be provided.

17. Prenatal and Postpartum Care Measure

This section fails to address the important interrelationship between weight and pregnancy. The measure should include the provision of information and counseling to pregnant women of: desirable weight gain, health effects of excess weight/weight gain on a healthy pregnancy/delivery, advantages of breastfeeding on the child's weight.

Post Partum Care:

Evaluation of Weight should not be alternative in the medical record. BMI should be recorded.

18. Experience of Care and Health Outcomes Status

This survey fails to capture BMI information. The satisfaction of members based on their weight status is important. There is an extensive literature on stigmatization by health care professionals on the basis of obesity.

19. Appropriate Medications for Persons with Obesity

New:

We propose that NCQA address the failure of managed care plans to incorporate FDA approved medications for the treatment of obesity, as it has for Medications for Asthma. In addition to addressing medications for obesity, this section should also address other medications which can result in weight gain.

20. Counting nurse practitioner visits or physician assistant visits as an MD visit.

We support this change as it can aid patient care especially in rural and underserved areas.

7. Conclusion

The failure of the managed care industry to face the obesity epidemic is intolerable.

Sufficient information about obesity, its treatments and efficacy exist for managed care organizations to start addressing the problem. The resources and information are in place. It is not adequate for NCQA to address these as future issues. The need for change is immediate.

Respectfully submitted,

Morgan Downey,

Executive Director

References

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