Obesity is a common, serious, and costly disease that increases people’s risk for morbidity and mortality.[1] It is characterized by abnormal or excessive body fat accumulation; weight loss and lifestyle changes have been shown to reduce the risk for associated negative health outcomes.[2]
Obesity treatment, which includes intensive behavioral therapy (IBT), anti-obesity medications (AOMs), and bariatric surgery, is underutilized, resulting in unmet potential benefits for the US health system and its patients.[3],[4] Recent advancements in AOMs showing efficacy to reduce weight beyond clinically significant thresholds have created new options for patients to achieve weight loss.[5],[6] Existing treatment guidelines recommend the use of AOMs and behavior change interventions for weight loss. However, Medicare does not cover AOMs[7] and has limited coverage and reimbursement for IBT[8]—policies that may reduce spending in the near term at the expense of both short- and long-term health and total costs savings.[9] Medicare Part D has statutorily excluded AOMs since it began in 2003, which implies that they were not considered essential for medical care. Clinical guidelines have since changed to recommend AOMs to treat obesity.[10] Aware of these limitations, the bipartisan Treat and Reduce Obesity Act of 2021, introduced in both the Senate and House, aimed to expand Medicare’s IBT benefit and allow for Medicare coverage of AOMs.[11]
This white paper, written at the request of Eli Lilly and Company, examines the Medicare obesity diagnosis and treatment landscape to identify barriers to patients’ access to obesity treatments. Our research is based on a review of the literature on Medicare policies regarding obesity diagnosis and treatment, national guidelines, incentives for providers, and patient and provider education.
We conclude that expanding access to obesity treatment in Medicare would benefit patients and the healthcare system. Such access should align with clinical best practices and national guidelines, which could lead to reduced obesity-related morbidity, mortality, and costs. Improved access to obesity treatment in Medicare would be consistent with improved access in the Federal Employees Health Benefits Program (FEHBP) and in the Veterans Health Administration (VA).
We make the following recommendations:
- Congress should authorize the Centers for Medicare and Medicaid Services (CMS) to align coverage policies with diagnosis and treatment guidelines, and CMS should further update reimbursement practices to adequately compensate providers of obesity treatment for the value of their services.
- CMS and contracted insurers should incorporate obesity treatments into existing performance-based incentive programs for insurers and physicians to encourage the treatment of obesity.
- While sufficient evidence already exists to justify expanding Medicare access to obesity treatments, including new AOMs, all stakeholders should invest in real-world evidence generation to further inform policies and practices that optimize long-term effectiveness of obesity treatments at the population level.
