Inadequacy of Coverage

It is no secret to primary care providers that reimbursement for obesity treatment is one of the great anomalies of the American health care system. Obesity is a serious disease associated with increased mortality rates and an independent cause of hypertension, type-2 diabetes, coronary artery disease, degenerative joint disease, and several types of cancer. These disorders are the most common, serious, and costly in our society. Yet, reimbursement for obesity treatment services is almost non-existent.

Overweight and obese individuals and the physicians who care for them feel a sense of injustice when health insurers pay for treating complications of obesity like type-2 diabetes, but will not pay for treatments that address the cause, obesity. In addition, many health plans cover other conditions that are not associated with the morbidity or mortality that obesity produces. Medicaid and other health plans cover prescriptions of Viagra™ for male erectile dysfunction, but do not cover many forms of obesity treatment. Few would argue that male erectile dysfunction is as serious a threat to health as obesity.

Because of this lack of coverage, more people are in need of obesity treatment services than are currently receiving them. For many overweight and obese individuals the costs of services are a deterrent to seeking and receiving treatment. They simply do not have adequate funds to pay for treatment out of pocket and so try to treat themselves with over-the-counter remedies and self-help books. The marketplace appears to be geared to produce obesity and profit on its treatment. Everything that it takes to become overweight seems cheap and plentiful, yet everything it takes to manage weight effectively costs time or money, and usually both. The obese patient gets little support from health insurance institutions.

What is Covered?

Medicare, the federal program for health services for the elderly and the disabled, does not consider obesity to be a disease or illness(1) and thus will make no payments for any services in connection with it. In some situations, the Medicare program does recognize gastric bypass surgery (2) as a form of treatment for diabetes or heart disease. Recently, Congress expanded coverage for medical nutrition therapy under Medicare but obesity is not on the list of covered diagnoses. Current legislation under consideration in Congress would expand Medicare by covering drugs for beneficiaries. Weight loss medications are excluded from all of the current proposals.

The Medicaid program, a joint federal-state program for the coverage of the poor and disabled, also does not recognize obesity as a disease. As with Medicare, some states do pay for obesity surgery, although the number of such claims and low reimbursement rates suggest that this benefit is not widely used. The federal statute governing Medicaid coverage of pharmacological compounds specifically excludes payment for drugs for weight loss. However, states can apply for a wavier from this provision. States covering no weight loss drugs include Illinois, Indiana, Nevada, New Hampshire, New York, Ohio, Oklahoma, South Carolina, South Dakota and Wyoming. States covering orlistat, sibutramine and phentermine include California, Delaware, Hawaii, Kentucky, Maine, Massachusetts, Mississippi, Montana, New Mexico, Oregon, Rhode Island, Vermont and Virginia. In some of these states, coverage is conditional on recipients either being morbidly obese or having hyperlipidemia or type-2 diabetes. The remaining states have coverage of less than the three products.

The Child Health Insurance Program, designed to bring more children under Medicaid coverage, does not cover obesity treatments. Other public programs, such as the medical programs of the Veterans Administration, the Indian Health Service and CHAMPUS, the program of the Department of Defense which covers military personnel and their dependents do not appear to routinely cover obesity treatments.

Private sector insurance is not much better. Some managed care companies and Health Maintenance Organizations do provide some support such as corporate wellness programs which incorporate weight management, prescription drugs, reimbursement for membership in weight loss programs, and surgery. Many programs require a comorbid condition such as hyperlipidemia or type-2 diabetes as a condition of covering weight loss treatments. Few companies have shown the leadership of General Motors, which not only covers treatments as part of their health plan but is also working in Flint, Michigan to develop a community-wide approach to healthier living.

Why is Insurance Coverage so Poor?

There are several putative reasons for this lack of coverage. There is a lack of understanding that obesity is a disease and a perception that treatments lack effectiveness. The size of the potential population which would utilize such a benefit threatens high costs, and beliefs about the role of personal responsibility in the etiology of the condition are often skewed.

In contrast to the lack of recognition by insurers, obesity is recognized as a disease by numerous scientific and medical authorities. These include the World Health Organization (3) , the National Academy of Sciences (4), the National Institutes of Health (5), the Food and Drug Administration (6), the Social Security Administration (7), the International Classification of Diseases (8), medical texts and other authorities. However, the concept of obesity as a disease has yet to gain wide popular acceptance among the public and health care professionals.

There is little doubt that the public and many physicians do not regard weight loss treatments as effective. To some extent, this is a carry-over from previous failures in obesity treatments. This view stems from the unrealistic goals that patients and professionals set for weight-loss treatment programs. To a certain extent, obesity treatments are held to a higher standard of effectiveness than other medical treatments. Many accepted therapies covered by insurance providers fail to produce a complete cure in many cases. For many chronic diseases, treatments are viewed as supportive or palliative and not necessarily curative. Compared to treatments for other lifelong serious conditions or malignancies, obesity treatments demonstrate reasonable effectiveness. (see chapter 17 on the National Weight Control Registry and chapter 14 on drug treatment of obesity). While all hope that the effectiveness of treatment modalities will improve over time, questions arise as to what level of effectiveness would be required before coverage would be extended. What criteria would be used to make such a decision? The development of newer, more effective therapies may be slowed by the perception that there will not be coverage for these therapies when they reach the market.

Payers have legitimate concerns about the financial exposure of covering a treatment for which millions of persons would be eligible. This is a real problem that needs to be addresses directly. However, creative and equitable solutions could and should be sought. Financial control could be exercised by reasonable combinations of limitations on the amount or duration of services, patient selection criteria, copayments and/or caps on annual or lifetime payments.

Beliefs about the role of personal responsibility and weight control are perhaps the most significant obstacles to health-insurance reimbursement. There is a widespread belief that overweight or obese individuals are responsible for their health problem and therefore insurance coverage is not appropriate. While it is true that personal behavior is involved in the genesis of the disorder, this argument has several problems. First, increasing evidence points to a biologic basis for obesity. Second, many health care conditions involve personal behavior. Hypertension, diabetes, sexually transmitted diseases, including HIV/AIDs, and sports injuries all are caused by or made worse by personal behavior that do not promote health. Some thirty-percent of all cancers, are reportedly due to diet, nutrition and physical inactivity. Yet no one says, "We won't pay for your diabetes or melanoma treatment. You did it yourself." The public and payers seem to see personal behavior as a more important cause of disease when it comes to obesity, an opinion not well supported by relevant science. Treatment costs for many of these conditions are covered by insurance, but obesity treatment costs are not.

Signs that Things are Changing

The situation can improve and has over the last several years. The American Obesity Association (AOA), an advocacy organization, has committed itself to expanding insurance coverage for obesity treatment. Success has been obtained in expanding recognition of obesity as a disease and in working on obtaining reimbursement.

Under previous Internal Revenue Service (IRS) regulations, expenses for weight loss could not be taken as medical-expense deductions. Earlier instructions to taxpayers had stated, "You cannot deduct the cost of weight loss treatment even if your doctor prescribes it."(9) In August of 1999, the AOA put together a coalition of organizations in a petition to the IRS to change this interpretation of the Internal Revenue Code. A year later, the IRS changed its instructions to read, "You can include in medical expense the cost of weight loss program undertaken at a physician's direction to treat an existing disease (such as heart disease). But you cannot include the cost of a weight-loss program if the purpose of the weight control is to maintain your good health." (10)

Subsequently, the AOA asked the Internal Revenue Service for a letter of public information as to whether treatment for obesity (defined as a Body Mass Index >30kg/m²) alone qualified for the deduction. The IRS responded on June 1, 2001. In their response, the IRS stated, "we are aware that there is considerable scientific and regulatory authority that obesity is, in and of itself, a disease…If obesity is a disease, then expenses for the diagnosis and treatment of obesity may qualify as expenses for medical expense. There are, however, certain limitations on the medical expense deduction that may apply to expenses for treating obesity. Expenses for medicines and drugs to assist in weight loss can be for medical care only if the medicine or drug is a prescribed drug or insulin…Additionally, while many obese individuals may follow special diets as part of their treatment, the cost of food is not an expense for medical care to the extent the food is a substitute for the food that an individual would normally consume to meet nutritional requirements. If a special diet is directed as treatment for a disease, only the excess cost of the special diet over the cost of a regular diet could be an expense for medical care."

Both the Social Security Administration and the Food and Drug Administration now acknowledge obesity as a disease as a qualifying condition for disability and in regards to the advertising restrictions on dietary supplements promoted as weight loss aids. (6,7)

The AOA has initiated a liaison with the American Association of Health Plans, the trade association for the managed care industry, to promote greater coverage of obesity treatment. The AOA continues to actively lobby Congress and the Executive Branch to include obesity treatment in the Medicare drug benefit proposals. The AOA has also distributed over two million brochures, Weight Management and Health Insurance to empower individuals to advocate with their employers for improved coverage.

In April 2001, the Centers for Disease Control and Prevention held a two-day workshop in Atlanta, GA on reimbursement for obesity treatment. A steering committee was formed and this group has begun an effort to develop a coalition of organizations which will provide ongoing leadership in this area.

What You and Your Patients Can Do

Individual physicians, other health care providers and their patients and families need to be proactive in obtaining improved reimbursement. Physicians should encourage patients to file for health-insurance coverage for obesity. If the claims are rejected, appeals should be filed. Patients should be encouraged to talk with their employers about including coverage. If the patients are not comfortable doing this, they should be encouraged to ask a coworker to be their advocate. Health care professionals should also take opportunities such as health fairs and meetings with state and federal elected officials to communicate the true picture of the obesity epidemic in the country and the need for treatment. Local and state medical societies and professional and business groups should be encouraged to take positions in support of obesity treatments.

In such efforts, confidence and persistence count. The health care system is paying millions of dollars treating disorders that could be prevented or ameliorated by sustained weight loss. The growing epidemic of obesity among children and adolescents means more potentially preventable morbidity and mortality in years to come, not to mention potentially avoidable health care expenditures. Advocates should insist that obesity be considered with the same standards used to make coverage decisions for other diseases. It is a form of discrimination to hold obesity treatment to standards that are not applied to other conditions. For example, payers sometimes want to see tangible proof that coverage of obesity treatments will save them money. However, they do not apply this standard to other therapeutic areas. Another strategy used by payers is to "condition coverage" of obesity treatments on the presence of type-2 diabetes or heart disease. This "cueing" is not wise health policy as it does not allow the benefits of obesity treatment used to prevent disease, and it is not used for other conditions. Treatment for diabetes is not withheld until complications develop.

Clearly issues of treatment, and which patients should be covered need to be addressed directly with an open and frank discussion of what standards are reasonable and appropriate. Always go through proper channels within insurance or managed care companies, e.g. customer services, director of customer services, marketing director. The medical director is a key individual in making coverage decisions. Patients who have medical savings accounts should be encouraged to put aside pre-tax dollars into such accounts for future employee expenses. Collect helpful supporting information. The NIH/NIHLBI Guidelines for the treatment of Adult Obesity can be very useful in demonstrating the acceptance and effectiveness of obesity treatment. The AOA website, www.obesity.org, is also a resource of materials useful for these efforts. (see chapter 20 for other useful web resources).

The situation will change. The obesity epidemic is simply too large to be ignored for much longer. New treatments are being developed. New studies are demonstrating the effectiveness of all forms of intervention. Professionals have a duty not only to be well informed about their patients and their disease and treatments; they have a duty to advocate for those who need help.

Finally, presumably large numbers of persons with obesity have no health insurance at all. Expanding insurance programs to cover more persons without any coverage is vitally important.

Morgan Downey is Executive Director of the American Obesity Association, Washington, D.C.

Insurance Coverage for Obesity Treatments is published as Chapter 19 in Evaluation and Management of Obesity, edited by Daniel H. Bessesen, MD and Robert Kushner, MD, 2002. Hanley and Belfus, Inc., Philadelphia PA.

1. Health Care Financing Administration Coverage Issues Manual 35-26.

2. Health Care Financing Administration Coverage Issues Manual 35-40.

3. Weighting the Options, Criteria for Evaluating Weight Management Programs, Paul R. Thomas, Editor, Institute of Medicine, National Academy Press, Washington, D.C. 1995.

4. WHO Press Release 46, 12 June 1997.

5. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults, The Evidence Report, National Institutes of Health, National Heart, Lung and Blood Institute, No. 98-4083, 1998.
p.xi.

6. Federal Register, January 6, 2000, Vol. 65, p. 1028.

7. Federal Register, Vol. 65, No. 94, May 15, 2000, p. 31039.

8. The ICD-9-CM lists "Obesity and other hyperalimentation" as #278 in the Endocrine, Nutritional, Metabolic and Immunity Disorders section.

9. IRS Publication 502 for 1999 tax year.

10. IRS Publication 502 for 2000 tax year.