BACKGROUND
Despite the high prevalence of obesity among U.S. adults, coverage for evidence-based obesity treatment modalities is inconsistent across states. The primary objective of this study was to examine changes in coverage for adult obesity prevention and treatment services within Medicaid programs and state employee health plans between 2009 and 2017.
METHODS
Changes in coverage were assessed by comparing data from plan year (PY) 2016/2017 to baseline data collected during PY 2009/2010. Data were obtained through an extensive review of administrative documents, health plan websites, provider manuals, subscriber handbooks, fee schedules, and drug formularies from Medicaid and state employee health insurance programs in all fifty states and the District of Columbia. Source materials were reviewed for indications of coverage and payment policies specific to evidence-based treatment modalities for adults (≥ 21 years of age) with obesity, including behavioral/nutritional counseling, pharmacotherapy, and bariatric surgery.
RESULTS
Like 2009, state programs were most likely to cover bariatric surgery and least likely to cover pharmacotherapy for members with obesity. Evidence of coverage for adult obesity treatment modalities increased in both Medicaid and state employee programs between 2009 and 2017, with more changes observed among state employee programs. The proportion of state employee programs indicating coverage increased by 37% for behavioral/nutritional counseling, 20% for pharmacotherapy, and 16% for bariatric surgery. The proportion of Medicaid programs indicating coverage increased by 18% for behavioral/nutritional counseling, 4% for pharmacotherapy, and 8% for bariatric surgery.
CONCLUSIONS
Our findings suggest that some states have bolstered coverage for evidence-based obesity treatment modalities in recent years. However, many states continued to deny reimbursement for non-surgical obesity treatment options that are supported by clinical consensus recommendations. Unclear guidance on what constitutes appropriate and reimbursable care for obesity-related services within Medicaid and state employee health programs likely prevents providers from referring highly-motivated beneficiaries with obesity to effective care. Where reimbursement for evidence-based obesity treatments has expanded, educating providers and beneficiaries on the availability and proper utilization of these services may improve obesity-related health outcomes
