Medicare Must Catch Up With the Science on Obesity – Inside Sources
- Medicare's current coverage for obesity treatments is limited, only covering certain behavioral therapies and bariatric surgeries while excluding effective anti-obesity medications due to outdated policies.
- The inadequate coverage of anti-obesity treatments under Medicare has significant health and economic consequences, potentially increasing the prevalence of diseases like diabetes and heart disease and burdening the healthcare system with higher costs.
- Advocacy groups are pushing for legislative changes, such as the Treat and Reduce Obesity Act, to expand Medicare coverage to include FDA-approved anti-obesity medications, which could significantly reduce obesity prevalence and healthcare costs.
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Introduction
In a time when scientific developments rapidly deepen our understanding of how to treat complex diseases, healthcare policies must keep pace. Obesity is a significant health issue that affects millions of Americans, and the medical community has made substantial strides in treating it. However, Medicare’s coverage for obesity treatments lags behind the science, leaving many patients without access to life-changing medications and procedures. This article delves into the current state of Medicare coverage for obesity treatments and highlights the need for policy changes to align with the latest medical advancements.
The Scope of Obesity in the US
Obesity is a leading risk factor for mortality in the United States. According to the National Institutes of Health, obesity and overweight are now the second leading cause of death nationally, accounting for an estimated 300,000 deaths annually. The medical costs associated with obesity are staggering, with an aggregate cost of $260.6 billion among adults in the United States. The issue is not just about individual health; it also significantly impacts the healthcare system and public health.
Current Medicare Coverage for Obesity Treatments
Medicare does cover some obesity treatments, but the options are limited. Intensive Behavioral Therapy for Obesity is covered under Medicare Part B, which includes no-cost obesity screenings and behavioral counseling for beneficiaries with a BMI of 30 or higher. This program provides initial assessments, nutritional evaluations, and ongoing counseling to promote long-term weight loss through dietary changes and exercise. However, these services are only covered in primary care settings, and referrals to specialists, such as registered dietitians, must be paid out of pocket.
For severe obesity (BMI of 35 or higher), Medicare covers bariatric surgery if it is determined by a doctor to be medically necessary. The types of bariatric surgery covered include sleeve gastrectomy, adjustable gastric banding, vertical gastric banding, Roux-en-Y gastric bypass, and biliopancreatic diversion with duodenal switch.
The Gap in Coverage – Anti-Obesity Medications
Despite significant advances in anti-obesity medications, Medicare does not cover these treatments. Anti-obesity medications (AOMs), such as glucagon-like peptide-1 (GLP-1) agonists, are increasingly recognized as effective options for weight management. These medications, including high-dose semaglutide and tirzepatide, have been shown to achieve an average weight loss of more than 10% at six months in clinical studies. However, the lack of coverage under Medicare means that only a small proportion of eligible patients receive these treatments.
The exclusion of AOMs from Medicare coverage stems from a provision in the Medicare Modernization Act of 2003 that excludes drugs labeled as “weight loss” or “weight gain” agents from the Part D prescription drug benefit program. This policy has been a subject of debate, with many advocating for changes to broaden access to these medications.
The Impact of Inadequate Coverage
The inadequate coverage for obesity treatments under Medicare has significant consequences. Many patients are left without effective treatment options, which can lead to a cascade of related health issues. For instance, without proper weight management, the risk of conditions like diabetes, high blood pressure, heart disease, and type 2 diabetes increases.
Researchers have estimated that if all eligible Americans had access to obesity treatments, the prevalence of obesity in the Medicare population would fall by 53% after the first decade. Additionally, the incidence of related diseases such as diabetes (5.5% reduction), hypertension (1.2%), and heart disease (1.7%) would also decrease.
Advocacy for Policy Changes
To address the gaps in coverage, advocacy groups such as the Obesity Action Coalition (OAC) are working on legislation to broaden access to treatment options for Medicare beneficiaries. The Treat and Reduce Obesity Act (TROA), a bipartisan bill, aims to enable the Centers for Medicare and Medicaid Services (CMS) to clarify that FDA-approved anti-obesity medications may be covered under Part D.
This legislation is crucial as it could significantly reduce healthcare costs. A USC Schaeffer Center white paper estimates that increasing access to obesity treatments would save Medicare approximately $175 billion in the first decade and $700 billion by the third decade.
Future Directions – Policy and Access
The future of obesity treatment under Medicare involves ensuring equitable access to diverse therapy options. Policymakers are exploring novel pricing solutions that allow for real-world evaluation of treatments while encouraging broad coverage. Outcomes-based valuation models could ensure that patients who need these therapies the most have access.
The path forward is complex, with Congressional Budget Office (CBO) scoring implications playing a significant role. However, recent policy developments, such as CMS’s clarification on covering AOMs with specific FDA-approved indications, offer hope for a more inclusive coverage landscape.
Conclusion
The need for Medicare to catch up with the science on obesity is clear. By broadening coverage to include anti-obesity medications and enhancing support for comprehensive treatment programs, policymakers can significantly improve health outcomes for millions of Americans. The current gap in coverage leaves many patients without access to life-changing treatments, exacerbating the already substantial health and economic burdens of obesity.
Advocacy efforts, legislative proposals, and innovative pricing models offer a pathway forward. It is imperative that healthcare policies evolve to reflect the latest medical advancements, ensuring that no one is left behind in the fight against this treatable but often undertreated condition.
References
- https://www.ncoa.org/article/obesity-treatment-and-medicare-a-guide-to-understanding-coverage/
- https://mann.usc.edu/news/medicare-coverage-of-weight-loss-drugs-could-significantly-reduce-costs-usc-schaeffer-white-paper/
- https://newsroom.heart.org/news/significant-gaps-between-science-of-obesity-and-the-care-patients-receive
- https://pmc.ncbi.nlm.nih.gov/articles/PMC498065/
- https://www.akingump.com/en/insights/alerts/anti-obesity-medications-noteworthy-developments-as-policymakers-weigh-coverage-considerations
