Obesity Toolkit FAQHow is metabolic syndrome defined?Overweight and obesity are associated with insulin resistance and the Metabolic Syndrome (MeS). However, the presence of abdominal obesity is more highly correlated with the metabolic risk factors than is an elevated BMI. Therefore, the simple measure of waist circumference is recommended to identify the body weight component of the MeS. Though the existence of MeS is often debated, there does exist a cluster of cardiovascular risk factors often associated with obesity. According to ATP III criteria1,2, MeS can be diagnosed when three of the following five diagnostic criteria are present: abdominal obesity, elevated glucose or triglycerides, reduced HDL cholesterol or hypertension3. Recent evidence suggests that treating patients once MeS has advanced to these diseases may not be cost effective. In a study of adults with MeS, researchers found drug costs were four times higher for these patients than the average annual drug costs for patients without MeS. Patient outcomes are also suboptimal in those with MeS, but new research suggests that treating the underlying causes of the condition could lead to better outcomes. What is meant by medical loss ratio?Medical loss ratio (MLR) is defined as the amount of revenues from health insurance premiums that is spent to pay for the medical services covered by the plan, usually referred to by a ratio, such as 0.96, which means that 96 percent of premiums were spent on purchasing medical services. The goal is to keep this ratio below 1.00—preferably in the 0.80 range, since the managed care organization's or insurance company's profit comes from premiums. Currently, successful HMOs do have MLRs in the 0.70-0.80 range. At what BMI is obesity defined?Obesity is commonly assessed by using body mass index (BMI), defined as the weight in kilograms divided by the square of the height in meters (kg/m2). A BMI of more than 25 kg/m2 is defined as overweight, and a BMI of more than 30 kg/m2, as obese. These markers provide common benchmarks for assessment, but the risks of disease in all populations can increase progressively from lower BMI levels.4 How can we most effectively engage health plans in adding obesity management programs?The summary answer is that the program must be manageable. An employer can recommend the concept to the insurer by demonstrating the population demand and emphasizing the need to address the obesity crisis, especially before the need for high cost bariatric surgery arises. The rider template is user-friendly for actuaries and benefit designers. At a medical loss ratio of 0.75, the health plan can offer the purchaser a product with quality, comprehensive information and still have 25 percent of the price to cover administrative costs and margin. This is one approach to consider. Do "behavioral services" include nutrition education? If so, is it done by a dietitian?Nutrition education is often one component of behavior-based and other clinical obesity interventions, but always in combination with other mechanisms of action. Recognizing their importance, registered dietitian access accounts for a significant component of the cost structure at Level 1 of the benefit. The toolkit goes into more detail regarding service providers. How sensitive is the model to lowering of obesity pharmacotherapy costs?The model is highly complex, and illustrations within the toolkit show various conclusions. The rider template model produces output that directly depends on the co-pays and can be highly customized if utilization assumptions are adjusted. Can providers bill for obesity management, even if it is provided online/telephonically vs. office visit?There is no single answer to this question. The particular insurance company covering the patient is the best source of information. How do you envision geographic access for Level 2 care?There are approximately 75 Level 2 clinics available. However, they are not organized as a commercial network at this time. 1. Third report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III). Final report. Circulation. 2002; 106: 3143-3421. 2. Scott M. Grundy, H. Bryan Brewer, Jr, James I. Cleeman, Sidney C. Smith, Jr, Claude Lenfant, and for the Conference Participants Definition of Metabolic Syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association Conference on Scientific Issues Related to Definition Circulation. 2004;109:433-438. 3. Heart, Lung and Blood Institute, NIH |
