Access to Care: Current Status, Healthcare Reform and Patient Advocacy

1. Access to Care: Current Status, Healthcare Reform and Patient Advocacy Joe Nadglowski President/CEO, Obesity Action Coalition (OAC) Executive Director, ASMBS Foundation

2. Access to Care: Current Status, Healthcare Reform and Patient Advocacy Presenter Name: Joe Nadglowski As previously disclosed, these are the companies with which I have a financial or other relationship(s): Company Name(s) Nature of Relationship(s) Obesity Action Coalition employment ASMBS Foundation employment

3. Access to Care:Are We Winning the Fight?

4. Simple Answer: Not Yet • Insurer and Employer coverage remains a problem in many parts of the country. • This is true particularly in the South and Central states. • Overall, government coverage remains good. • Expanded restrictions on coverage: • Requirements for surgery, such as documented history and medical weight management, are limiting care in some states that previously were considered “good coverage” states (i.e. New Jersey). • Although NCD under Medicare should have improved access to Medicare beneficiaries, data suggests number of Medicare surgeries is falling. • NCD has not translated, to date, to a landslide of new coverage but many groups have adopted Medicare’s restrictions. • There is no core coverage for bariatric surgery except in Indiana and New Hampshire (beginning September 2008). Both via mandate.

5. Coverage Landscape Large Employer Coverage (self-insured) declined in 2007 Mercer, 2007

6. Coverage Landscape • Three states, (Indiana, Maryland and in 2008, New Hampshire) have mandates requiring bariatric surgery be included as a core benefit in state regulated policies. Mandates do not impact self-insured plans. Note, some state mandates do not apply to individual plans. • Individual plans, generally, do not cover bariatric surgery. • In most states, small employers still cannot purchase a rider to offer coverage at any cost. • A couple of states (notably Georgia and Virginia) require such a rider to be offered, but they are usually priced too high for any employer to consider. • Major Question: Will the economy affect insurance coverage?

7. Coverage Landscape (cont.) Government • Federal employees, military and Medicare beneficiaries have coverage. • 42 of 50 states offer coverage* for their employees. • Non-coverage states include: Montana, Idaho, Utah, Kansas, Oklahoma, Texas, Louisiana and South Carolina. • Georgia and Mississippi added coverage in 2009. • Texas (via legislation) and Kansas (via health plan decision) have indicated coverage starts in 2010. • Coverage is defined as having at least one plan paying for bariatric surgery. • 47 states offer coverage under Medicaid. • Non-coverage in Ohio, Kansas and Mississippi

8. Coverage Landscape (cont.) Restrictions on Coverage • Pre-surgical requirements are limiting coverage (documentation of morbid obesity and required medical weight management). • However, some victories have been seen in this arena including dropping medical weight management (BCBSAZ) and shortening and/or easing sources of documentation of both history of morbid obesity (Aetna) and medical weight management (Cigna). • Guidelines specifically excluding certain patients are problematic as well. • For example: Horizon BCBS and coverage for those with BMI greater than 60 and Trailblazer (Medicare) limiting access to those with certain mental illnesses.

9. Coverage Landscape (cont.) Medicare • Although difficult to determine exact number of procedures (billing code issues), it appears that Medicare volumes have dropped by at least 1,000 procedures on an annual basis since the NCD (11,800 to 10,700). • Industry estimates show an even more dramatic drop, as Medicare was estimated at 15% of the market in 2005. Current numbers would put that number at about 5%. • Both coverage issues (local carriers restricting access) and reimbursement are contributing to this fall. • There is limited evidence of new coverage based on the NCD among private insurers. Most assumed coverage would follow with private insurers as they often follow Medicare.

10. Coverage Landscape (cont.) No Core (or Basic) Benefit • Sentiment is increasing for such a benefit with the quality of recent data. • But, current economic landscape could be dangerous for coverage.

11. Is Healthcare Reform the Solution?

12. Status of Healthcare Reform House of Representatives • House narrowly passes HR 3962, The Affordable Health Care for America Act (220 to 215). • House Speaker Pelosi (D-CA) makes concessions to secure House passage but House “victory” now complicates Senate effort to pass reform. Obesity Action Coalition

13. Status of Healthcare Reform Senate: It’s beginning to look a lot like Christmas • HELP and Finance Committees have reported out reform packages. • Senate Majority Leader Harry Reid (D-NV) must meld competing versions into single package for Senate floor debate and vote (December). Obesity Action Coalition

14. Key Issues Between the Chambers • Cost: $1.1 Trillion versus $829 Billion • Financing: Taxing Americans Vs Insurance Companies • Public Plan: Mandatory versus “State opt-out” • Coverage: 36 Million versus 29 Million • Subsidies & Coverage Penalties • Abortion Obesity Action Coalition

15. Michigan Delegation HOUSE HEALTH CARE COMMITTEES: Dingell*, Camp, Upton, Levin, Stupak, Rogers, Kildee, Ehlers, Hoekstra SENATE HEALTH CARE COMMITTEES: Stabenow* * Sponsor of Major Medicare Physician Payment fix bill Obesity Action Coalition

16. Rep. Dave Camp (R-MI) “They’ve (the House and Senate) really kind of taken two different forks in the road on health reform. This is very complicated, it’s a long way from being over and many of these provisions are integrated with one another. You can’t just pick and choose off a list and slap it together.” Obesity Action Coalition

17. Surgical Community ASMBS Joins 20 other surgical groups, including the American College of Surgeons in reiterating “serious concerns with several provisions that were included in the Senate Finance approved bill… if concerns are not adequately addressed in the melded reform package that is brought to the Senate floor, we will have no other choice but to oppose the bill.” Obesity Action Coalition

18. Medicine/Seniors Support House Bill American Medical Association, American College of Surgeons, American Cancer Society, AARP have signed onto the House Bill for both what’s in it as well as for what is not included in the House package Obesity Action Coalition

19. Challenges? • Lack of Obesity treatment language in any current bills. • Employer Sponsored Wellness incentives/penalties – will House language stick?. • Taxing of “Cadillac” Health plans in Senate Finance Bill – will this discourage treatment coverage? • Medical Device Manufacturer’s Tax – will this raise the price of bariatric procedures? • SGR not fixed in either bill except for 1st year. • Independent Medicare Advisory Committee (IMAC) better known as “MedPAC on steroids” given unprecedented authority and not required to receive congressional authority. Obesity Action Coalition

20. Obesity-Related Provisions • House Language on Incentives Minimize the use of unproven “incentives” by requiring the study of the effectiveness of such provisions to help both the company and the employee AND such incentives can not be “tied to the premium or cost sharing of an individual under any qualified health benefits plan” Obesity Action Coalition

21. OAC/ASMBSGetting Specific on Reform • Any Standard Health Care Benefit Plan should specifically include obesity counseling and treatment services as outlined by evidence-based guidelines developed by the National Institutes of Health or its various institutes. Obesity Action Coalition

22. Politico Ad – November 9, 2009

23. OAC & ASMBS Advocacy • Monthly Trips to Capitol Hill over last nine months • Initial and follow-up visits with Majority Staff from House Ways & Means and Energy & Commerce and Senate HELP and Finance Committees • Initial and follow-up visits with staff with House Speaker Nancy Pelosi and Senate Majority Leader Harry Reid • Solidifying relationships with key legislators like Senators Bingaman, Harkin and Bayh; Representatives Kind and Blumenauer • Establishing Relationships Within the Hall of States • Meetings with State Offices of FL, GA, MD, NM, NC, SC and VA • Meetings with the National Governors Association and its Center for Best Practices Obesity Action Coalition

24. OAC & ASMBS Advocacy • Growing Patient Access Partnerships with Medicine & Industry • Meeting with CMS on NCD re Surgery for Diabetes • Invitation to join Surgical Quality Alliance • ASMBS Rapid Response Team & OAC/ASMBS STAR Programs • Partnership events at 2009 ASMBS Annual Meeting • Participation in STOP Obesity Alliance Surgeons General Briefing • Invitation to address Southern Governors Association • Participation in upcoming TOS Policy Session on HCR and Obesity • Enhanced Comm. & Coordination through Access to Care Committee Obesity Action Coalition

25. Moving Forward: How Do We Improve Access? Needs • Numbers: We still lack the ability of other disease state organizations to bombard an office with calls, emails, faxes and visits. This includes both patients and professionals. • Increased local presence. All politics is local. • Explicit pathways, guidelines and rationale for coverage policies • i.e. What a model coverage policy should look like, including obesity history requirements, pre-surgical weight-loss attempts, psychological counseling, exclusions, etc. • COE’s to accept Medicare and cover their own employees • Some COE’s refusal to accept Medicare patients hurts our efforts with private insurers as well as leaves one of most needy populations (the disabled and the elderly) without care.

26. Moving Forward: How Do We Improve Access? Needs (cont.) • Industry partners to present a united front on policy issues through a third party industry association or the ASMBS. • As we address access to care, we also need to be cognizant of reimbursement as well. It is not enough to just create coverage if procedures aren’t going to be provided due to poor reimbursement. • Make access to care an community wide priority.

27. Advocacy – The Answer to Improving Access • Advocacy is defined as the act of pleading or arguing in favor of something, such as a cause, idea or policy. • Advocacy comes in many forms - it can be communicating with elected officials, government regulators, insurers, employers, the media and the general public.

28. Does Advocacy Work? YES! Examples include: • Elimination of Blue Cross/Blue Shield of Tennessee’s IQ Testing Requirement for those Seeking WLS • Passage of New Hampshire mandate led by a bariatric surgery patient who is also a legislator, Senator Bob Clegg • The withdrawal of House Bill 282 that discriminated against those affected by obesity • Protection of Virginia’s bariatric surgery benefit for state employees in early 2009.

29. What Challenges do We Face with Advocacy? • Convincing healthcare professionals that they are able to advocate and that their voice counts when advocating. • Convincing those affected by obesity that they are capable of being effective advocates and that their advocacy efforts domake a difference.

30. Why Should You Advocate or Encourage Advocacy? • Simply, because it works. • Legislators, regulators, insurers, employers, the media and the public want to hear from the direct beneficiaries of their actions. • Many successful advocacy efforts, especially in the healthcare industry, were either patient-driven or had direct patient involvement.

31. General Advocacy Tips • Be patient – It takes a long time to pass a law or change perceptions. Get patients involved in the process and explain to not expect instant results. • Build relationships – Every interaction is important. Our democratic process is never completely finished. Be helpful and constructive and don’t burn bridges. • Be brief, but powerful – Encourage patients and staff to say it in five minutes or on one page. Legislators, regulators, etc. are extremely busy facing numerous issues. • Encourage confidence in the process– Voters are powerful and government is organized to serve the public.

32. How the OAC Can Help • The OAC was created to fill the patient advocacy gap. • By building a nationwide network, the OAC empowers patients to be effective advocates for change. • Advocacy efforts of the OAC focus on access to care issues. The OAC believes those who need access to insurance coverage for obesity management services, including bariatric surgery, should not be denied. • The OAC can serve as your source of patient advocacy resources and materials.

33. Education An innovative way for healthcare professionals to encourage patient advocacy is through the OAC’s newest video, titled “Taking Action with the Obesity Action Coalition.” Legislators need to hear from YOU!. Download Today at www.obesityaction.org/multimedia/supportgroupvideo.php Obesity Action Coalition

34. Contact the OAC The OAC assists those on a continual basis with advocacy efforts and offers numerous tools available for those wishing to be proactive advocates. Obesity Action Coalition 4511 North Himes Ave., Suite 250 Tampa, Florida 33614 (800) 717-3117 Fax: (813) 873-7838 www.obesityaction.org info@obesityaction.org