Employer Obesity Workgroup

Challenges

"We are an Association coordinating benefits for 270 employer groups/locations state-wide. Our employees have two medical carriers to choose from and we've found that while there is higher enrollment in one plan than the other, the plan with the lower enrollment has a higher percentage of enrollees with obesity. Getting desired claims data from health plans has been challenging — coding rates for obesity are generally low, as it's not a diagnosis that is often used, which is further complicated in that we are unable to pull claims data for more than one diagnosis at a time to capture any of the conditions identified as common comorbidities and occurring with a diagnosis of obesity. Another challenge we acknowledge is our current lack of coverage for any weight loss medications."

Solutions

• Data warehouse provides more accessible data
• Field engagement with members to assess what benefits matter
• Broad wellness program suite addressing obesity and concurrent conditions: dietary coaching, mental health coaching, general health coaching, consulting nurse, condition management, no-cost EAP, quarterly wellness newsletter, staff trainings including annual Healthy Worksite Summit, personalized wellness app, and mini-grants for healthy workplace initiatives
• Dedicated Health Promotion staff
• Member feedback via Employee Benefit Advisory Committee and Board of Trustees
• Adopted January 2023: bariatric surgery benefit through carrier's Centers of Excellence ($35k lifetime max) with unlimited nutritional counseling visits
• Evaluating a telehealth point solution for MSK conditions that often accompany obesity

Results

• Multiple member testimonials cite bariatric, MSK, and nutritional counseling coverage as keeping people at work
• Thorough data review informs more tailored coverage decisions
• Coverage for weight loss medications for patients with diabetes now on the radar as a possible future focus
• Consistent health and wellness culture maintained across 270+ employer groups
• Upper 20% EAP utilization rate

Challenges

"We've found claims data from one of our plans to be less transparent and less readily available and our current data may be inflating patient counts when a patient has multiple diagnoses. The data needs more analysis. We need to review current lifestyle modification programs for more condition-specific and culturally competent options. We've seen poor program utilization and an employee focus group has expressed resistance for one vendor due to perceived obesity bias and lack of cultural representation. Our members have requested more coverage for weight management, and we have also seen escalating cost of GLP-1 prescriptions for off-label use without a diabetes diagnosis."

Solutions

Results

• Actuarial data presented to benefits oversight committee — balancing pharmacotherapy costs with member impact and outcomes
• Shifting philosophy: treating medication for obesity as a chronic condition, the same as other conditions

Challenges

"Obesity is under-reported in our data: .058% of enrolled members had a claim with a principal diagnosis of overweight or obesity. Meanwhile, 14% have related diagnoses of dyslipidemia, diabetes type 2, hypertension or metabolic syndrome."

"Although weight loss drugs are currently excluded from coverage, 27% of members in the PPO plan who received Ozempic did not have a diagnosis of diabetes. Ozempic ranks 7th highest in drug spend over the last 12 months, at a trend of 118%."

Solutions

• Prior authorization process instituted for GLP-1 drugs to end off-label prescribing

Results

• 2022: 800 adult members participated in weight care programs (5.4% of target group)
• 2022: 1,100 employees participated in online exercise programs
• Ending off-label GLP-1 prescribing conservatively estimated to save over $1 million annually
• Drug coverage for weight loss excluded pending further research

Challenges

"Although 54% of our population have a chronic condition with a comorbidity of obesity, we have challenges with engagement. Coverage of pharmacotherapy is currently strictly for diabetes management, but members have requested coverage for weight management as well. We also recognize the need to offer coverage for minors."

Solutions

• Mirroring discussions about weight management medication coverage to those about other chronic condition medications
• Monitoring trends with PBM: coverage for weight management medications among other purchasers has risen from 20% to 45–50% for some medications
• Bariatric surgery covered with prior authorization
• Developed state-wide SDOH map of the covered population to address care gaps
• Point solution options implemented for rural PPO members with MSK conditions associated with obesity
• Exploring weight management programs for minors

Results

• Added coverage for shorter-term weight loss medications (excluding Ozempic, Rybelsus, and Wegovy due to long-term dosing requirements) for self-insured plans
• Discussions underway to expand coverage to additional plans
• Point solution implementation under assessment; potential expansion to HMO members being evaluated