treating obesity in medicaid - amazon s3 obesity in medicaid scott kahan, md, mph director, national...
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Treating Obesity in Medicaid
Scott Kahan, MD, MPH Director, National Center for Weight and Wellness
Clinical Director, Strategies to Overcome and Prevent (STOP) Obesity Alliance
George Washington University School of Public Health [email protected]
Agenda
• Overview of obesity treatment • Overview of obesity coverage in Medicaid
Redefine Success
Knowler WC, et al. NEJM 2002.
3234 adults with obesity and “pre-diabetes”
Placebo Metformin Lifestyle
Self-Monitoring
0
5
10
15
20
25
30 0 Records Kept
1 to 2 Records Kept
3 to 4 Records Kept
5+ Records Kept
Month 3 Month 6 Month 9 Month 12
Wei
ght L
oss (
lbs)
Steinberg DM, et al. Obesity 2013;21(9):1789-97. JADA, 1991.
Meal Replacements versus Low Cal Diet
American Journal of Clinical Nutrition, 1999.
Ongoing Guidance and Support
0
2
4
6
8
10
12
14
16
18
Wei
ght L
oss (
%)
Months
No maintenance visitsMaintenance visits
5 10 15
Perri, et al. JCCP 1988;56:529-34.
Obesity Counseling in Primary Care
Moyer VA, et al. Ann Intern Med 2012;157:373-8. Post RE, et al. Arch Intern Med. 2011;171:316-21.
Obesity Counseling in Medicare
Current CMS coverage in primary care settings: • 1 face-to-face visit weekly for the first month • 1 face-to-face visit biweekly for months 2-6 • 1 face-to-face visit monthly for months 7-12 (if 6.6 lb loss)
“Intensive behavioral therapy for obesity…is reasonable and necessary for the prevention and early detection of illness and disability and is appropriate for
individuals entitled to benefits [under Medicare].”
CMS. Decision memo for intensive behavioral therapy for obesity (CAG-00423N). November 29, 2011.
• Counseling, support, and guidance – Individual counseling and group classes – Weekly initially, reduced thereafter
• Self-monitoring • Calorie-reduced diet
– 1200-1500 kcal/day if <250 lb – 1500-1800 kcal/day if >250 lb
• Portion-controlled meal replacements – 3/day in months 1-4, reduced thereafter
• Physical activity – Gradual escalation to 175 min/week and 10,000 steps/day
Look AHEAD Research Group. Diab Care 2007;30:1374-83..
Look AHEAD Trial
Obesity, 2009.
Look AHEAD: Weight Loss at 1 Year
Look AHEAD Trial
Look Ahead Research Group. Arch Intern Med 2010;170(17):1566-75.
Louisiana Obese Subjects Study
Ryan DH, et al. Arch Intern Med, 2010.
FDA-Approved Obesity Pharmacotherapy Options
• Phentermine (and other noradrenergic agents) • Orlistat (Xenical/Alli) • Lorcaserin (Belviq) • Phentermine/topiramate ER (Qsymia) • Bupropion SR/naltrexone SR (Contrave)
Phentermine/Topiramate ER: 2-Year Weight Loss
Garvey WT, et al. Am J Clin Nutr. 2012;95(2):297-308.
Phentermine/Topiramate ER Prevents Progression to Diabetes
3.7%
1.7%
0.9%
0
0.5
1
1.5
2
2.5
3
3.5
4
Placebo Phen/TPM CR 7.5/46 mg Phen/TPM CR 15/92 mg
Prog
ress
ors
per y
ear (
%)
Garvey WT, et al. Am J Clin Nutr. 2012;95:297-308.
P=0.0078
76% P=0.1514
54%
Annualized Incidence of T2DM
Orlistat
Torgerson JS, et al. Diabetes Care. 2004;27:155-161.
Orlistat and Prevention of Diabetes
Torgerson JS, et al. Diabetes Care. 2004;27:155-161.
Combination Therapy
Adapted from Wadden, et al. NEJM, 2005.
Placebo alone Medication alone Lifestyle modification alone Combined therapy
Bariatric Surgery
New England Journal of Medicine, 2007.
Bariatric Surgery: At Least 5% Weight Loss at 10 Years
New England Journal of Medicine, 2004.
Bariatric Surgery: Improvement in Health Problems
• Diabetes 76.8% • High cholesterol 70.0% • Hypertension 61.7% • Obstructive sleep apnea 85.7%
Journal of the American Medical Association, 2004.
2008 State-by-State Analysis of Medicaid Coverage
8 states covered all 3 treatment categories
Lee JS, et al. Public Health Rep. 2010;125(4):596-604.
Nutrition counseling Pharmacotherapy Bariatric surgery • 26 states explicitly
included • 20 states excluded
• 10 states explicitly included, with most states requiring preauthorization
• 8 states excluded • 33 states had
no mention of pharmacotherapy in their provider manuals
• 45 states included • 3 states explicitly
excluded
Coverage of Obesity Services in Medicaid (2012)
• Reviewed state Medicaid provider manuals, fee schedules, and drug formularies
• While all states’ Medicaid programs covered at least one obesity treatment modality, few states offer comprehensive coverage across multiple modalities
• Few states provide guidelines for obesity prevention and treatment (0 states for adult beneficiaries; only 4 states for EPSDT beneficiaries) despite expert clinical consensus guidelines existing from a number of organizations, including the NHLBI, AAP, ASN, and the Endocrine Society, among others
Prevention: 7 states cover all obesity-related preventive care codes; 21 states cover none
Map 1: Medicaid Coverage of Obesity-Related Preventive Counseling Services
RI
WA
MT
ID OR
CA NV
UT
NM AZ
KS
TX
CO
IA
AR OK
ND
SD
NE
LA
WY WI
IL
TN
MS
MO
MN
AL
KY
OH
MI
IN
NC
VA
SC
GA
WV
NY
PA
FL
NJ DE
MD
CT
MA
NH VT ME
HI
AK
Covers all obesity-related preventive counseling services
Covers some obesity-related preventive counseling services
Covers no obesity-related preventive counseling services
Undetermined/No Data Available
Source: CPT Code Search of Provider Fee Schedules Note: Common Preventive Counseling Services are defined as CPT codes 99401-99404 and 99411-99412
DC
Divine L, Kahan S. Public Health Reports (in press).
Nutrition: 6 states cover all obesity-related nutritional consult codes; 22 states cover none
Map 2: Medicaid Coverage of Obesity-Related Nutrition Counseling Services
RI
WA
MT
ID OR
CA NV
UT
NM AZ
KS
TX
CO
IA
AR OK
ND
SD
NE
LA
WY WI
IL
TN
MS
MO
MN
AL
KY
OH
MI
IN
NC
VA
SC
GA
WV
NY
PA
FL
NJ DE
MD
CT
MA
NH VT ME
HI
AK
Covers all obesity-related nutritional consult services
Covers some obesity-related nutritional consult services
Covers no obesity-related nutritional consult services
Undetermined/No Data Available
DC
Source: CPT Code Search of Provider Fee Schedules Note: Common Nutritional Consult Services are defined as CPT codes S9452, 97802-97804, S9470
Disease Management: No states cover all obesity-related disease management CPT codes;
30 states cover none
RI
WA
MT
ID OR
CA NV
UT
NM AZ
KS
TX
CO
IA
AR OK
ND
SD
NE
LA
WY WI
IL
TN
MS
MO
MN
AL
KY
OH
MI
IN
NC
VA
SC
GA
WV
NY
PA
FL
NJ DE
MD
CT
MA
NH VT ME
HI
AK
Covers all obesity-related disease management and education services
Covers some obesity-related disease management and education services
Covers no obesity-related disease management and education services
Undetermined/No Data Available
DC
Source: CPT Code Search of Provider Fee Schedules Note: Common Disease Management and Education Services are defined as CPT codes 99078, S0315-S0316, S9445-S9446, 98960-98962
Map 3: Medicaid Coverage of Obesity-Related Disease Management and Education Services
Behavioral Counseling: 2 states cover all obesity-related behavioral consult CPT codes;
23 states have no coverage
RI
WA
MT
ID OR
CA NV
UT
NM AZ
KS
TX
CO
IA
AR OK
ND
SD
NE
LA
WY WI
IL
TN
MS
MO
MN
AL
KY
OH
MI
IN
NC
VA
SC
GA
WV
NY
PA
FL
NJ DE
MD
CT
MA
NH VT ME
HI
AK
Covers all obesity-related behavioral consult and therapy services
Covers some obesity-related behavioral consult and therapy services
Covers no obesity-related behavioral consult and therapy services
Undetermined/No Data Available
DC
Source: CPT Code Search of Provider Fee Schedules Note: Common Behavioral Consult and Therapy Services are defined as CPT codes 96150-96155, S9499, S9451
Map 4: Medicaid Coverage of Obesity-Related Behavioral Consult and Therapy Services
29
Medications: 12 states cover obesity medication, generally with restrictions and prior
authorization; 34 states explicitly exclude
Map 5: Medicaid Coverage of Obesity Pharmacotherapy
Bariatric Surgery: 44 states cover bariatric surgery; 5 states explicitly exclude
RI
WA
MT
ID OR
CA NV
UT
NM AZ
KS
TX
CO
IA
AR OK
ND
SD
NE
LA
WY WI
IL
TN
MS
MO
MN
AL
KY
OH
MI
IN
NC
VA
SC
GA
WV
NY
PA
FL
NJ DE
MD
CT
MA
NH VT ME
HI
AK
Covers bariatric surgery
Explicitly excludes bariatric surgery
Undetermined/No Data Available
DC
Source: State Medicaid Provider Manuals
Map 6: Medicaid Coverage of Bariatric Surgery
