Employer Action Steps

Obesity Management Toolkit

Download Checklist
  1. Assessing Your Population Needs

  • Think differently about individuals who are overweight or have obesity and focus on a holistic, whole-person approach.
  • Assess your population’s needs, awareness of and perceived value of existing offerings, as well as unmet needs using culture audit surveys, open enrollment meetings, focus groups and/or interest surveys.
  • Identify gaps in current program offerings, particularly for under-represented, high-risk populations, such as minority populations and low-wage workers.
  • Elicit feedback regarding your work environment as well as organizational policies and practices to identify opportunities to improve alignment with obesity management goals.
  1. Using Your Data

  • Measure the prevalence of obesity in your population to understand the total organizational impact it may have on health care and associated costs as well as opportunities to maximize program effectiveness and guide strategic planning.
  • Use data from these sources to identify and quantify opportunities to maximize effectiveness to guide strategic planning:
    • Biometric screenings and health risk assessments
    • Participation rates and outcomes of all existing obesity and lifestyle management program offerings; stratify results to gain a better understanding of the differences in engagement and outcomes between different workforce population subgroups
    • Medical claims data from the health plan/TPA or consultant/broker using ICD-10 codes for bariatric surgeries and other obesity-related medical procedures
    • Pharmacy claims data from the PBM or consultant/broker regarding use of AOMs and related medications for comorbid conditions
    • Workers’ compensation costs, particularly among individuals identified as having obesity
    •  Cost and value generation of obesity-related lifestyle and disease management programs

 

  1. Strategic Planning & Benefit Design

  • Evaluate gaps in existing program integration (e.g., lack of cross-referrals between lifestyle management offerings and weight management programs, or lack of AOM use among post-operative bariatric surgery patients who are regaining weight despite intensive lifestyle management) and develop mitigation plans.
  • Promote equitable access to essential obesity management treatments by considering a Value-Based Insurance Design (V-BID). This strategy provides access to high value services with minimal cost sharing – for the appropriate population, these services could include consultations with a registered dietitian, AOM’s (when certain criteria are met) and in some cases, bariatric surgery
  • Review approaches to and the effectiveness of incentives, rewards and other offerings.
  • Ensure telemedicine coverage includes obesity management offerings to address the needs of at-risk populations and those who may have limited access to trained clinicians.
  • Develop a strategic plan and offer comprehensive weight management offerings that incorporate evidence-based approaches along with consideration of member interests and preferences.
  • Ensure multiple program and benefit options are available to members based on where they are in their health and well-being journey.
  • In advance of implementation, formalize the program evaluation process, including leading, intermediate and lagging indicators, and establish a timeline and frequency for reporting.

 

  1. Implementation

  • Integrate education and awareness using a robust communication strategy.
  • Reinforce all programs offered and related benefit options frequently so they are top of mind when individuals are ready to engage.
  • Ensure an ongoing review of participation and outcomes reporting to provide timely input/modifications to enhance program impact.

 

  1. Working with Vendor Partners

  • Ensure all vendors (health plans, point solution vendors, EAP/referral services) are informed of plan features and support options. Make sure each agrees to conduct cross-referrals of eligible participants with other vendors and request reporting on at least a quarterly basis.
  • Establish that your health plan maintains an adequate provider network including board-certified obesity medicine physicians, registered dietitians (certified to treat clinical conditions), nutritional counselors and behavioral health clinicians who have expertise in obesity management and can offer treatment at in-network rates. This will help eliminate barriers for people needing appropriate care in the right setting at the right time.
  • Determine if your health plan has a list of accessible Centers of Excellence (COEs) for bariatric surgeries.
  • Identify COEs for bariatric surgery treatments (gastric band, gastric sleeve and bypass procedures) and require they provide regular reporting on outcomes, complications rates and re-admissions. COEs are more likely to produce successful outcomes at a lower total cost of care.
  • Ensure COEs also have a plan for intensifying lifestyle management for individuals who experience considerable post-operative weight regain.

 

  1. Using Anti-Obesity Medications

  • Perform an opportunity assessment to determine whether the need exists for AOM use – see PBM Prior Authorization Criteria for AOMs.
    • Quantify the estimated costs and potential value on investment based on the number of qualified users
    • Use ICD-10 codes based on individuals with multiple (4 or more) comorbidities as these individuals often have a high prevalence for obesity but may not be coded as such
  • Evaluate the opportunity to include AOM coverage and the potential implications for added administrative costs from the PBM for doing so; make sure there are no issues and/or fees related to customizing and/or expanding the formulary.
  • Determine which AOMs are available and the clinical criteria the PBM is using to establish eligibility as well as the prior authorization process and step therapy expectations.
  • Model potential costs/impact based on possible tier placement of AOMs and select tiers based on business priorities such as cost or comorbidity management.
  • Select formulary tier placement that is broad enough for short- and long-term coverage to achieve sustainable outcomes (so that tier placement is not financially prohibitive to members).
  • Ensure step therapy is defined by clinical criteria, including:
    • Reviewing the guidance around the use of each medication
    • Defining the appropriate population
    • Determining dosing and length of treatment
  • Ensure the PBM formulary positions AOMs so they are not classified as a lifestyle medication as this may limit access to those who need them most.
  • Address plan exclusions that may deny AOM coverage by evaluating the formulary to ensure barriers are eliminated based on clinical criteria. In PBM plan design documents:
    • Check “Yes” in section that covers AOMs
    • Select appropriate coverage within the prior authorization section of the document or “benefit specification form”
  • To expand coverage, include addenda, riders, certificate of coverage and exclusion language:
    • Addenda provide supplemental coverage to a base health plan policy and can be incorporated at any time (for self-insured health plans)
    • Riders are added to the base health plan policy that expands coverage (subject to state policies and deadlines for fully insured health plans)
  • Review the actual language in the certificate of coverage used by the health plan to ensure medical claims will not be denied.
  • Communicate AOM coverage changes to all members, keeping the language simple, and using real-life examples to help with explanations.
  • Develop and implement quarterly reporting regarding AOM use, including prescribing and adherence rates, AOM treatment-related weight loss outcomes and reductions in use of medications for obesity-related comorbidities (as a component of potential savings).
  • Ensure the payer/health plan covers obesity counseling services (e.g., dietitians, obesity management physicians, health coaches) to help individuals build knowledge, confidence and skills to achieve their weight management goals.