Addressing Obesity through Benefit Offerings

Obesity Management Toolkit

Employer Action Steps

Benefit offerings that support evidence-based interventions for lifestyle modification, disease management, anti-obesity medications and appropriate surgical interventions are critical for long-term success.

Treatment Options – Medical Benefit

Primary Care Physicians

As a chronic condition, obesity, like type 2 diabetes, hypertension, high cholesterol, can and perhaps should be managed in the primary care setting. However, there is wide variability in the level of formal obesity management training for primary care physicians (PCPs). Additionally, significant clinician time is generally spent on near-term priorities such as management of chronic conditions to achieve target treatment goals (a central focus for care management and clinician revenue generation). The PCP management of patients who are overweight or have obesity should include the following:

  1. Calculate a Body Mass Index (BMI) and code obesity as a diagnosis.
  2. Address and treat any risk factors for heart disease and obesity-related comorbidities.
  3. Screen for symptoms of depression and other mental health issues; consider referral to behavioral health clinician with expertise in weight management and depression.
  4. Develop and implement a treatment plan that includes dietary guidelines, an exercise regimen that is appropriate given the risk factors, and refer to a registered dietitian, as appropriate.
  5. Consider referral to weight management programs, such as those provided by an employer or available in the community.
  6. Establish regular follow-up visits to determine if the patient is achieving success (3% to 5% weight loss) and if not, consider referral to a board-certified obesity medicine specialist.

Obesity & Weight Loss Specialists

Alternatively, physician-led weight management centers can offer holistic treatment through a multi-disciplinary approach and include treatment and consultation of nutritionists, nurse practitioners and behavioral psychologists.

Centers of Excellence (COE)

COEs are typically located within health care institutions. They offer programs with a high level of expertise in a particular area of medicine focused on the best possible outcomes and fewer complications for patients. Common specialty areas include oncology, cardiology, orthopedics and bariatric surgery, and may also include comprehensive weight management programs.

Facilities that are accredited as COEs for bariatric surgery support continuous quality improvement by implementing defined standards of care, documenting outcomes and participating in regular reviews to evaluate their bariatric surgical programs. The Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program accredits inpatient and outpatient bariatric surgery centers in the U.S. that have undergone an independent, voluntary peer evaluation in accordance with nationally recognized bariatric surgical standards.

 

Treatment Options – Pharmacy Benefit

Although lifestyle modification is a foundational component of any weight loss intervention, alone, it may not always be sufficient to achieve sustained weight loss. For appropriate individuals who are overweight or have obesity and are not responding to lifestyle modification, medications can fill a critical need. Employers must understand the distinction between the different types of obesity management medications to ensure they optimize access to the right treatments.

The U.S. Department of Health & Human Services National Institute of Diabetes and Digestive and Kidney Diseases offers information on what prescription medications are approved to treat patients who are overweight or have obesity, including for whom the medication is approved, how it works, common side effects and warnings. A good first step is to determine what criteria the PBM has in place for the following:

  • Traditional weight-loss medications – FDA approved, controlled substances (typically in generic form); often not covered by pharmacy benefit plans because of having only a short-term indication (up to 12 weeks) as well as potential side effects, including addiction potential; these require a prescription.
  • Anti-obesity medications (AOMs) – FDA approved, can be use for short-term and long-term or chronic weight management for appropriate individuals who are overweight or have obesity; these require a prescription.

A July 2021 JAMA Study on the Effectiveness of Combining Antiobesity Medication with an Employer Weight Management Program for Treatment of Obesity included the following key points:

Performance-Based Contracting

More employers are requiring point solution vendors and health plans agree to performance guarantees in their contracts. The real employer examples below from MBGH employer members are based on various scenarios to address weight management.

Employer A

  • We conducted a pilot program with a leading provider (vendor) of weight management and disease prevention for a single site that had the highest BMI scores. We agreed to pay an upfront cost of $50 per participant to cover the cost of a Bluetooth scale.
  • At the end of six months, if individuals achieved a 5% or greater weight loss, we paid the vendor the balance of the cost of the service for the outcomes achieved. Our members did very well and the vendor deemed the program a success. We have expanded the program to other locations beyond the pilot site.

Employer B

  • Most of our point solutions have a tiered approach to billing. Participants must meet certain weight or Hemoglobin A1C criteria or complete a predetermined number of sessions.
  • For example:
    • Milestone 1: Billed $695 when the participant first engages
    • Milestone 2: Billed $150 after 30 days if the participant averages 4 or more sessions over the previous 4 weeks
    • Milestone 3: Billed $150 after 60 days if the participant averages 8 or more sessions over the previous 8 weeks

Employer C

  • We rely on our pharmacy strategy consulting partner and PBM to provide appropriate prior authorization criteria to ensure the right medication, right time, right patient, right cost and right reasons.
  • In the future, we plan to negotiate:
    • Outcomes-based, risk-based, value-based performance guarantees with drug manufacturers in a direct contract or through the PBM/manufacturer.
    • “Fees-at-risk” as part of an outcomes-based contract where the drug manufacturer or PBM issues a credit for any suboptimal outcomes on an annual basis.

When to use AOMs

Anti-obesity medications are not appropriate for everyone. Prescribing within this medication class is individualized and necessitates matching patient characteristics with the appropriate product. AOMs are recommended as an adjunct to lifestyle modification when an individual experiences:

  1. Failure on lifestyle therapies to achieve desired weight loss
  2. Weight regain after initial success on lifestyle therapies
  3. Weight-related complications, especially if they are severe

In addition, health care professionals often use BMI to determine who might benefit from weight-loss medications. Based on prescribing criteria, two categories of patients may be considered for AOMs:

  • Those with a BMI of 30 or more
  • Those with a BMI of 27 or more with weight-related comorbidities, such as high blood pressure and/or type 2 diabetes

According to the FDA, AOMs can be used in addition to a reduced-calorie diet and increased physical activity for some cases of obesity. Employers desiring to incorporate AOMs into their obesity management strategic planning should consider the following:

  • Establish that AOMs are covered under the plan.
  • Determine which are included on the drug formulary.
  • Although the FDA considers approved AOMs chronic weight management medications, some PBMs classify them as lifestyle medications on the formulary which may limit access to those who need them most.
  • Consider providing guidance around use of the medication, defining the appropriate population, dosing and duration based on clinical evidence.
  • Understand the clinical criteria the PBM is using to approve use of these medications. If none are established, encourage the PBM to put these in place or set up prior authorization to ensure the medications are used as intended.

Common Weight Loss Medications

This chart provides information on brand/generic weight loss medications, including a description of each medication and how the medications are classified (controlled substance, requires a prescription, available over-the-counter, etc.). This information helps the employer have a broad understanding of available product offerings. Check to determine if your PBM can provide you with updated information on what is available in the market. (For illustrative purposes only)

Patient costs for AOMs range from $11 to $1,334 per month. Not all AOMs are covered by insurance plans but manufacturer and pharmacy coupons are often used to offset patient costs. Currently, the FDA has approved five anti-obesity drugs for long-term use.

PBM Prior Authorization Criteria for AOMs

Like any other disease treatment, matching patient needs to the medication regimen to determine the most appropriate treatment is critical to achieving the best results. For AOMs, PBM prior authorization criteria should necessitate ongoing, periodic (every 3 month) BMI monitoring with evidence of continued patient weight loss to justify continued medication use. The PBM policy should also include criteria for AOMs that address the following indications for medication discontinuation:

  • Patient has achieved normalization of BMI
  • Patient is no longer losing weight while compliant with medication
  • Patient’s failure to achieve near-term weight loss goal (e.g., 4% body weight lost over 12-16 weeks)

Review this Weight Loss Agents Prior Authorization with Quantity Limit Program Summary from a health plan based on coverage requirements for successful duration of weight loss for generics and brand medications. (For illustrative purposes only)