Obesity

1. Obesity Managing the Growing Epidemic Kathleen Sullivan, R.D. First Florida Insurance Brokers July 10, 2013

2. Obesity is increasing rapidly in all subgroupsIncreases in obesity in the USA: 2000–2010 • Between 2000 and 2010, the proportion of Americans who were morbidly obese (BMI > 40) rose from 3.9% to 6.6% - an increase of 70%. • More than 15 million adult Americans are morbidly obese (BMI > 40) Estimated values. Sturm R and Hattori A. Morbid obesity rates continue to rise rapidly in the United States. Int J Obese 2012; 1:1-3.

3. And it’s not expected to get betterFuture projections for obesity and morbid obesity 2010 and 2020 data projected based on data through NHANES 2003-2004. Centers for Disease Control. NCHS Health E-Stat. Retrieved April 22, 2011 from http://www.cdc.gov/nchs/data/hestat/overweight/overweight_adult.htm Ruhm C. Current and Future Prevalence of Obesity and Severe Obesity in the United States. Forum for Health Economics & Policy 2007; 10(2):Article 6.

4. 2010 Obesity RatesObesity is an epidemic Overweight 1 out of 3 Children 2 out of 3 Adults Obesity Rates Among US Adults (BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) 1989 2010 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Centers for Disease Control. US Obesity Trends. Retrieved April 2, 2011 from http://www.cdc.gov/obesity/data/trends.html and http://www.cdc.gov/obesity/downloads/obesity_trends_2009.ppt

5. Leading Causes of Morbidity and Mortality in the US Top Five Annual Costs • Tobacco $193 billion • Obesity $147 billion • Inactivity $201 billion • Diabetes $181 billion • Heart Disease and Stroke $498 billion All linked to obesity

6. Obesity also a risk factor for other diseases “Overweight and obesity are major risk factors for a number of chronic diseases, including diabetes, cardiovascular diseases and cancer.” World Health Organization (WHO) See end of presentation for references

7. Obesity is a disease …not just what you eat “Obesity is a chronic disease as defined by the WHO, NIH, CDC and ADA.” (1) MedTAP, 2007 “Obesity is a complex … chronic disease that … involves the integration of social, behavioral, cultural, physiological, metabolic and genetic factors.” (2) National Institutes of Health, 1998 Genetic factors may account for as much as 80% of a person’s tendency to develop obesity3 “More people drive long distances instead of walking, live in neighborhoods without sidewalks, tend to eat out or get ‘take out’ … Our environment often does not support healthy habits.”4 A person’s chance of becoming obese increased by 57% if he or she had a friend who became obese; by 37% if his or her spouse was obese.5 1. Oregon Health Resources Commission. Medical management of obesity MedTAP report, June 2007. 2. National Institutes of Health. Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults. NIH Pub # 98-4083. 3. Maes HHM, Neale MC, Eaves LJ. Genetic and environmental factors in relative body weight and human adiposity. Behavior Genetics 1997; 27(4)325-351. 4. National Institutes of Health. Understanding Adult Obesity. Retrieved April 22, 2011 from http://win.niddk.nih.gov/publications/understanding.htm#environmental 5. Christakis NA and Fowler JH. The spread of obesity in a large social network over 32 years. New England Journal of Medicine 2007; 357:370-379.

8. Morbid obesity’s cost is in more claimsMore worker’s comp claims compared to normal weight Per 100 FTE Østbye T, Dement JM, Krause KM et al. Obesity and workers’ compensation: Results from the Duke Health and Safety Surveillance System. Arch Intern Med. 2007;167:766-773

9. The Medical Costs of Obesity 1,2 America’s Health Rankings. Obesity. Retrieved April 2, 2011 from http://www.americashealthrankings.org/obesity.aspx 3 Finkelstein EA, Trogdon JG, Cohen JW et al. Annual medical spending attributable to obesity: Payer and service-specific estimates. Health Affairs 2009; 28(5):w822-w831.

10. The Steps Taking One Bite at a Time

11. Getting Started or Infusing New Fuel • Planning is critical to success • Institute of Medicine Accelerating Progress in Obesity Prevention: Solving the Weight of the Nation • http://www.iom.edu/Reports/2012/Accelerating-Progress-in-Obesity-Prevention/Report-Brief.aspx • Florida School District Employee Wellness Partnership • 30 schools & 3 colleges ( 280,000 EE’s) • Created guide http://www.healthydistrict.com/resources/employee-wellness/. • Carol Vickers, RN,FL Dept. of Health 850-245-4444 ext. *2794carol_vickers@doh.state.fl.us • In Polk, Nassau, Osceola and Sarasota County Schools reported significant reduction in health care costs and/or reduction in care risk index improved • Health is Academic – selling point why health is so important to the academic out put of the population – Coordinated School Health Model

12. Grants to Tap Into • Department of Health provides: • Weekly updates Chronic Disease Prevention Partners • IE. webinars, events and grant opportunities in Fl. • Email: mr_street@doh.state.fl.us • Grant support • Deborah Saulsbury, MPH, RD deborah.saulsbury@med.fsu.edu • Florida Chronic Disease Prevention Implementation Plan (CD-PIP) • Phone: 904-230-0884  • Often can provide self-monitoring blood pressure equipment for each site blood pressure tracking cards, fact sheets and other resourcesto raise awareness and facilitate self-management. 

13. Goal: Make Schools a National Focal Point For Obesity Prevention Message Environments School Environments Physical ActivityEnvironments Food and BeverageEnvironments Health Care And Work Environments National Institute of Medicine Goal for Schools

14. Strengthening Schools as the Heart of Health

15. Create a Culture of Health Physical Exercise Community Partnerships Onsite Champions Nutrition Policy

16. Incentives for obesity-related services and programs

17. Charging More Under ACA, Insurers Can Charge More For Smoking, Being Overweight. Sensitivity with Unions… FOX News(5/30, Angle) reported “For smoking, for being overweight, for being obese and basically, for generally not meeting the health guidelines, the employer can charge 30 percent more – for smoking, 50 percent more.”

18. Partnership With your insurance carrier • Data sharing is vital • Carriers provide screening, disease management, some wellness programs, online tools • Incentives • CASH contributions to the program to support a coordinator • Polk County partnered with Florida Blue to screen 6,133 EE’s for Glucose, HBP, TC/LDL/HDL. EE’s ID to be at risk were referred to disease & care management and Private MD

19. The Clinical Side

20. NIH Recommendations for Treating Obesity SURGERY BMI 35+ with co-morbidities BMI 40+ Continuum of Care PHARMACOTHERAPY BMI 27+ with co-morbidities BMI 30+ LIFESTYLE MODIFICATIONS BMI 25+ Adapted from the National Institutes of Health. The practical guide: Identification, evaluation, and treatment of overweight and obesity in adults. 2000; NIH Publication Number 00-4084.

21. Overweight: Lifestyle Modification • Effectiveness of Treatment • A one-year randomized trial of Atkins, Zone, Weight Watchers and Ornish was performed to determine their real effectiveness and sustainability for weight loss and cardiac factor reduction. • Results • Each diet significantly lowered HDL/LDL ratio by 10% • Weight loss and cardiac risk reduction only occurred for the minority of individuals who sustained a high dietary adherence level. Lifestyle Modification Diet Programs Physical Activity Behavior Modification Dansinger ML, Gleason JA, Griffith JL et al. Comparison of the Atkins, Ornish, Weight Watchers, and Zone diets for weight loss and heart disease risk reduction: a randomized trial. JAMA 2005; 293(1):43-53.

22. Lifestyle Modification Weight Loss BMI 25+ Develop policy and programs to support entire population • Weight loss programs • Department of health, local hospitals, private companies i.e.. Weight Watchers, Jenny Craig, Nutrisystem • Full time resources – dietitians, health coaches • Weight loss support groups • Private consultations with registered dietitians • Prevention and Health Education Services • Disease Self-Management and Education Services • Programs for Kids

23. Scalable delivery to reach dispersed and diverse population

24. Pharmacotherapy BMI 27+ w/ co-morbidities or BMI 30+ • Obesity: Lifestyle Modification + Medical Management Treatment Options • Effectiveness of Treatment • “The amount of extra weight loss attributable to these drugs is modest and no evidence indicates that any particular drug promotes more weight loss than another drug…. All of the drugs have side effects.” (1) MedTAP • Results Lifestyle Modification Diet Programs Physical Activity Behavior Modification Medical Management Weight Loss Drugs 1 Oregon Health Resources Commission. Medical management of obesity MedTAP report, June 2007. 2 Genentech, Roche – Xenical prescribing information 3 Gate Pharmaceuticals; ePocrates – Adipex-P monograph Data in table from Li Z, Maglione M, Tu W et al. Meta-analysis: Pharmacologic treatment of obesity. Ann Intern Med 2005; 142:532-546.

25. Severe Obesity or Morbid Obesity: • Why Bariatric Surgery? Treatment Options • “Weight-loss surgery is the most effective treatment for morbid obesity producing durable weight loss, improvement or remission of comorbid conditions, and longer life.”SAGES (2009) • Bariatric surgery is linked to decreased overall mortality, particularly deaths associated with diabetes, heart disease and cancer. MedTAP (2006) • “Surgical intervention in obesity significantly reduces the risk of DM [diabetes mellitus] and the risk of future mortality and is cost effective.” AACE (2011) Lifestyle Modification Diet Programs Physical Activity Behavior Modification Medical Management Weight Loss Drugs Bariatric Surgery* 1 SAGES Guideline Committee. SAGES guideline for clinical application of laparoscopic bariatric surgery. Surg Obese Rel Dis 2009; 5:387-405 2 Oregon Health Resources Commission. Bariatric surgery MedTAP report. October 2006. 3 Handelsman Y, Mechanick JI, Blonde L et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocrine Practice 2011; 17(S2):1-53.

26. Surgery BMI 35+ w/ co-morbidities or BMI 40+ • Require employees to be treated by Centers of Excellence • Through health plan or (TPA) • Assess current Bariatric Policy to include: • Gastric Banding • Gastric Bypass • Sleeve Gastrectomy • Incentivize patients for long-term follow-up • Waive copays for choosing COE • Reimbursement patient co-pay overtime for keeping the weight off • Pay for plastic surgery with compliance to follow up MD/Care team

27. Bariatric Surgery is a Wise InvestmentCase study of average costs over the first 5 years Surgical costs recouped: 3.5 years Mullen DM, Marr TJ. Longitudinal cost experience for gastric bypass patients. Surg Obese Rel Dis 2010; 6:243-248.

28. Bariatric Surgery Complication & Mortality Rates Comparable to Common Surgical Procedures (CMS) CMS MedPAR data on file, Ethicon Endo-Surgery, Inc.

29. Reasons to changeEE Turnover rates : Voluntary Data is supplied by the U.S. Department of Labor, Bureau of Labor Statistics (BLS). 29

30. ODS OregonObesity Management program • Objective • Establish and implement a weight management benefit that provides treatment access for full BMI range. • Benefit • The benefit covers Weight Watchers, physical activity access, behavioral health and bariatric surgery. • Implementation Details • Depending on BMI and waist circumference, a member enters into a care pathway that will include access to a combination of interventions. For instance, if a member has a BMI of 30, they will have access to Weight Watchers, physical activity access and behavioral health. • Change in Culture • This is an entirely new way for a health plan to address the issue of obesity and morbid obesity. The approach has been put in place to assist members to lose and maintain weight as well as to encourage positive weight loss habits such as support groups.

31. MGMAn Innovative Benefit Objective Create a surgical weight loss alternative to those meeting specific qualifications which will ultimately help members achieve a healthier status. Benefit The bariatric surgery benefit is covered, and the $5,000 member co-pay can be reimbursed if the patient fulfills specific criteria after 2 years. An additional $5,000 cosmetic surgery benefit is available upon fulfillment of an additional goal at 4 years. Implementation Details Surgery can only be performed at a designated center. Members qualify for reimbursement of the initial out of pocket copay if member achieves yearly weight loss goals out to 4 years. Qualification for cosmetic surgery incentive occurs if member has reached weight loss and support group goals. Change in Culture This is an entirely new way for a health plan to address the issue of obesity and morbid obesity. The approach has been put in place to assist members to lose and maintain weight as well as provide bariatric surgery for those members in need of an effective intervention for a higher BMI.

32. Contact Kathleen Sullivan, VP, Risk Management kathleen.sullivan@ffinsbr.com A graduate of the University of Connecticut, with a major in Clinical Dietetics, Kathleen brings an expertise in building clinical delivery systems, efficient plan administration and comprehensive population health management. Her career in the group health insurance industry spans over 20 years and is marked by successful stints at Aetna, Oxford HealthPlans and HealthPlan Services.