As the audience is undoubtedly aware, the prevalence of obesity is increasing and is often referred to as an “epidemic” but some of the statistics as presented in this slide (and subsequent slides) are startling. The reasons for this explosion in obesity are multifactorial and not easily remedied. However, for those that are already obese, there are treatments available that are effective. Given the high prevalence of obesity in children, the epidemic is not going to lessen, but will continue to increase for the foreseeable future. Therefore, taking advantage of the available treatments is imperative. 1. Bannerman B. Obesity and Bariatric Surgery. CDHC Solutions. http://www.cdhcsolutionsmag.com/archives/2006/06-June/CDHC_Jun06_Bariatric.pdf. Accessed March 28, 2007. 2. Department of Health and Human Services - National Institutes of Health. BMI Categories. http://www.nhlbisupport.com/bmi/. Accessed March 27, 2007. 3. American Obesity Association. Obesity in the U.S. http://www.obesity.org/subs/fastfacts/obesity_US.shtml. Accessed April 25, 2007. 4. Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The epidemiology of obesity. Gastroenterology 2007;132:2087-2102. 5. Department of Health and Human Services - National Institutes of Health. The Problem of Overweight Children and Adolescents. http://www.surgeongeneral.gov/topics/obesity/calltoaction/fact_adolescents.htm. Accessed September 19, 2007.
The slide is taken directly from the CDC presentation, Obesity Trends Among U.S. Adults, available at http://www.cdc.gov/NCCDPHP/dnpa/obesity/trend/maps/obesity_trends_2008.ppt#472,2,Obesity Trends Among U.S. Adults between 1985 and 2008 (Accessed Sept 9, 2009). Slide is from the CDC website http://www.cdc.gov/NCCDPHP/dnpa/obesity/trend/maps/index.htm In 1990, among states participating in the Behavioral Risk Factor Surveillance System, 10 states had a prevalence of obesity less than 10% and no states had prevalence equal to or greater than 15%. By 1998, no state had prevalence less than 10%, seven states had a prevalence of obesity between 20-24%, and no state had prevalence equal to or greater than 25%. In 2008, only one state (Colorado) had a prevalence of obesity less than 20%. Compared to 2007, the number of states with a prevalence equal to or greater than 30% has doubled, from 3 (Alabama, Mississippi and Tennessee) in 2007 to 6 in 2008. The data shown in these maps were collected through CDC’s Behavioral Risk Factor Surveillance System (BRFSS). Each year, state health departments use standard procedures to collect data through a series of monthly telephone interviews with U.S. adults. Prevalence estimates generated for the maps may vary slightly from those generated for the states by BRFSS (http://aps.nccd.cdc.gov/brfss) as slightly different analytic methods are used.
Medical complication of obesity – Obesity impacts almost every function in the body
Why are we as a nation becoming obese?
Showing how portion sizes have changed in the US.
Portion sizes are larger
It may be of interest to note the obesity ranking for the state in which you reside. I live in TX and we rank #15 but with 24,326,974 this represents a large amount of people. Rates of obesity continued to rise across the country during the past year. Thirty-seven states saw an increase in obesity, and 24 of these states experienced an increase for the second year in a row. Nineteen states experienced an increase for the third straight year. Obesity rates did not decrease in a single state. 2008 report: Mississippi leads the nation in obesity with its #1 status, while Colorado is the least obese state, coming in at #51 ( data set includes PR.) Last year Mississippi was the only state with obesity rates over 30 percent, but this year Mississippi, still ranked most obese at 31.7 percent, has been joined by West Virginia and Alabama -- 30.6 percent and 30.1 percent respectively. Mississippi also has the highest rate of physical inactivity and hypertension, and tied for the second highest rate of diabetes. Alabama and West Virginia also ranked in the top 10 for highest rates of physical inactivity, hypertension and diabetes. Now, only 22 states have rates of obesity less than 25 percent, compared with 31 from last year -- losing 9 states to the 25-percent-orgreater category. In Colorado, the leanest and only state under 20 percent, rates of obesity increased from 17.6 percent to 18.4 percent. The U.S. Department of Health and Human Services (HHS) set a national goal to reduce adult obesity rates to 15 percent in every state by the year 2010. Currently, all states and the District of Columbia exceed 15 percent. This data is from Trust for America's Health 2008 Report, which is published annually.
Direct cost of chronic diseases in the United States It is estimated that obesity accounts for 6% of the nation’s total healthcare expenses, with $51.6 billion/year in direct costs and over $100 billion/year in both direct and indirect costs. Direct costs include the costs of personal health care, hospital care, physician services, allied health services, and medications. Indirect costs include the value of lost productivity from illness or premature mortality. The estimated direct cost of obesity is comparable to that of other prevalent, chronic diseases, such as type 2 diabetes and coronary heart disease, and is more costly than both hypertension and stroke. Moreover, obesity contributes to the development of other chronic diseases; it is estimated that 61% of the direct cost of type 2 diabetes, 17% of the direct cost of coronary heart disease, and 17% of the direct cost of hypertension are attributable to obesity. Wolf AM, Colditz GA. Current estimates of the economic cost of obesity in the United States. Obes Res. 1998;6:97-106. Hodgson TA, Cohen AJ. Medical care expenditures for selected circulatory diseases: opportunities for reducing national health expenditures. Med Care . 1999;37:994-1012.
The Hispanic population is disproportionately impacted by obesity compared to whites. You can see from the chart on the left that Blacks (in the dark blue) are most at risk for obesity, followed by Hispanics (represented by the white bar). In Texas, 32% of the Hispanic community is obese vs. 23.5% of whites.
Call out a few additional obesity statistics with Texas and particularly children and physical activity.
Chart breaks down the dollar costs annually as a direct result of obesity. Direct health care costs are only a portion of the cost of illness.
Both versions of HB 4630 & SB 2113 were filed and referred to committee in their respective houses but did not receive hearings. However, their contents were amended to SB 871 outlined below and were in addition to the filed version of SB 871 that allowed institutions of higher education to participate in the wellness program and required the Employee Retirement System to annually report to the legislature on the results of the risk assessments. As filed the bill would have amended the Texas Government Code by adding the following statutory duties to the Statewide Wellness Coordinator’s existing requirements for the coordination of the State Employee Wellness Program; create an online questionnaire for state agency heads to report information, including: the agency policy on leave time for employees to complete a health risk assessment; the agency policy on leave time for employees to receive an annual physical examination; the agency policy on providing employees time during the workday to exercise; and whether the agency has a wellness coordinator or council. Additionally the bill also required that A state agency shall create a worksite wellness policy that is annually updated and submitted to the statewide wellness coordinator. The executive head of a state agency shall submit the agency's worksite wellness information to the statewide wellness coordinator annually through the online questionnaire The bill also provided that a state agency shall provide four hours of leave time each year to an employee who completes either an online health risk assessment tool provided by the board or a similar health risk assessment conducted in person by a worksite wellness coordinator. HB 3327 Castro/SB 870 Lucio SB 870 was effective 9/1/09 S.B. 556 in 2007, established the Texas Interagency Obesity Council (council). The council is comprised of the commissioners of the Texas Education Agency, the Department of State Health Services, and the Texas Department of Agriculture (TDA). The council was created for the coordinating and improving current health-related initiatives and should be directed to continue its efforts. S.B. 870 expanded the duties of the council and TDA relating to health wellness, and prevention of obesity and the establishment of an obesity prevention pilot program. The council shall create an evidence-based public health awareness plan. In creating the plan, the council shall explore past successful public health awareness efforts, a cost estimate that accounts for continuing implementation of the plan, recommendations on reaching populations that would most benefit from increased public health awareness and recommendations on encouraging employers to participate in wellness programs for employees. The commission and the Department of State Health Services shall coordinate to establish a pilot program designed to decrease the rate of obesity in child health plan program enrollees and Medicaid recipients, improve the nutritional choices and increase physical activity levels of child health plan program enrollees and Medicaid recipients, and achieve long-term reductions in child health plan and Medicaid program costs incurred by the state as a result of obesity.
Review SB 2577 and provisions of the bill
SB 2577 added an additional benefit to state employees, however unlike most benefits or mandates, it was done without cost to the state or the employee retirement system trust fund. Since the state of Texas is on a two year budget cycle, it was imperative to economically prove that within this time frame there would be no additional budget cost to the state. This was achieved by drafting a bill that created a 24 month maximum ROI for the insurance plan, thereby eliminating any fiscal impact that the state could have incurred by adding a new benefit.
One proposed benefit design ERS may implement. The employee will incur some costs for this additional benefit, but it will be structured similar to benefits within commercial insurance plans.
(Bill You Sponsored)
Various options for legislation to address obesity
Increase in healthcare costs among obese compared with normal (BMI <25 kg/m2) patients Obesity is associated with increased outpatient and inpatient medical costs. This figure shows the relative increase in the cost of healthcare services required by obese compared with lean members of a health maintenance organization (HMO) in northern California. These healthcare services can be divided into three categories: 1) outpatient healthcare visits, outpatient pharmacy services, outpatient laboratory services, 2) total outpatient services, total inpatient services, and 3) total cost of health care. Among the 17,118 members of this HMO, there was a 25% increase in total healthcare costs in those with class I obesity (body mass index [BMI] 30.0-34.9 kg/m 2 ) and a 44% increase in total healthcare costs in those with class II or III obesity (BMI 35 kg/m 2 or greater), compared with lean patients (BMI 20.0-24.9 kg/m 2 ). The increased healthcare costs for obese patients was largely a result of costs related to coronary heart disease, hypertension, and diabetes. Quesenberry CP et al. Obesity, health utilization and health care costs among members of a health maintenance organization. Arch Intern Med . 1998;158:466-472.
The clinical approach to obesity can be viewed as a pyramid consisting of several levels of therapeutic options. All patients should be involved in an effort to change their lifestyle behaviors to decrease energy intake and increase physical activity. Lifestyle modification also should be a component of all other levels of therapy. Pharmacotherapy can be a useful adjunctive measure for properly selected patients. Bariatric surgery is an option for patients with severe obesity, who have not responded to less-intensive interventions. The number of obese patients who require a specific level of treatment decreases as one moves up the pyramid.
In addition to similar long-term efficacy, LAGB is widely acknowledged to be a safer procedure than GBP—not only in terms of surgical mortality, but in major/total complications as well. Objective complication rating system (e.g., III or IV) vs. a subjective rating system (e.g., minor or major) focuses on the diagnostic tests and therapeutic procedures required to treat a complication rather than the complication itself, which tends to eliminate the subjective interpretation of severity and surgeons’ natural tendency to down-rate complications. [Parikh, 2006] 1. Parikh MS, Laker S, Weiner M, Hajiseyedjavadi O, Ren CJ. Objective comparison of complications resulting from laparoscopic bariatric procedures. J Am Coll Surg. 2006;202(2):252-261. 2. Chapman AE, Kiroff G, Game P, et al. Laparoscopic adjustable gastric banding in the treatment of obesity: a systematic literature review. Surgery. 2004;135(3):326-351.
Given that it is accepted that obesity leads to increased mortality, one important question has always been whether obesity interventions (especially those that are effective in maintaining long-term weight loss) could not only lead to weight loss and reductions in comorbidities, but also whether there would be a reduction in mortality that could be substantiated. In the past several years, a number of studies have examined this question comparing death rates in patients that had undergone bariatric surgery (in some cases, just gastric bypass, in others any bariatric procedure, and in still others, only LAP-BAND™ System) to controls. Although statistical methodologies varied somewhat and the sources of control patients also varied, the results strongly suggested a survival benefit for patients who had bariatric surgery. Hazard ratios of death in these analyses ranged from 0.11-0.76 (a hazard ratio of 0.5 would equal a halving of the risk of death; a hazard ratio of 1 would equal no change in the death rate). In recent studies of patients who had undergone LAP-BAND™ System surgery, the reductions in mortality were dramatic and statistically significant. These studies are extremely important evidence demonstrating one of the most crucial clinical benefits a treatment can have—improved survival. 1. Christou NV, Sampalis JS, Liberman M, et al. Surgery decreases long-term mortality, morbidity, and health care use in morbidly obese patients. Ann Surg 2004;240:416-424. 2. Flum DR, Dellinger EP. Impact of gastric bypass operation on survival: a population-based analysis. J Am Coll Surg 2004;199:543-551. 3. Sj ö str ö m L, Narbro K, Sj ö str ö m D, et al. Effects of bariatric surgery on mortality in Swedish obese subjects. NEJM 2007;357:741-752. 4. Adams TD, Gress RE, Smith SC, et al. Long-term mortality after gastric bypass surgery. NEJM 2007;357:753-761. 5. Peeters A, O’Brien P, Laurie C, et al. Substantial intentional weight loss and mortality in the severely obese. Ann Surg 2007 [In Press]. 6. Busetto L, Mirabelli D, Petroni MI, et al. Comparative long-term mortality after laparoscopic adjustable gastric banding versus non-surgical controls. Surg Obes Relat Dis 2007;3:496-501.
The initial investment for bariatric surgery is approximately $26,000 for open surgery and $17,000 for laparoscopic surgery. After taking into account age, sex, and comorbidities, the initial investment is returned within 4 years for patients who undergo open surgery and within 2 years for patients who undergo laparoscopic surgery. Even ignoring potential quality-of-life and length-of-life benefits, as well as disability and work loss, third-party payers can rely on bariatric surgery paying for itself through decreased comorbidities within 2 to 4 years. Bariatric procedures should not be held to a different standard Allergan is happy to see the body of evidence growing on the cost effectiveness of bariatric surgery and gastric banding in particular. Using standard Health Outcomes measures, LAP-BAND® is cost-effective in the treatment of morbid obesity. Some studies indicate that LAP-BAND® is more cost-effective than gastric bypass due to fewer severe and more costly complications LAP-BAND® results in significant, rapid, and sustained improvement in health-related quality of life (HRQoL), resulting in levels comparable to community-based norms An important area of focus that is not included in an ROI analysis is the significant impact on presenteeism absenteeism, workers comp, etc. for obese employers before and after LAP-BAND® surgery. That being said, Allergan is pursuing studies that provide a more comprehensive societal and economic analysis of the effects of LAP-BAND® surgery than a simple ROI. Ultimately, LAP-BAND® should be covered and accessible to all patients who are at least 18 years old and a BMI ≥ 40 or a BMI of ≥ 35 with one or more comorbidities
Rep Lucio Obesity PPT
Addressing the Obesity Crisis in Texas State Representative Eddie Lucio III November 20, 2009
Agenda <ul><li>Obesity Statistics </li></ul><ul><ul><li>Prevalence </li></ul></ul><ul><ul><ul><li>Nationally and in the Hispanic Population </li></ul></ul></ul><ul><ul><ul><li>Health and State Implications </li></ul></ul></ul><ul><ul><li>Causes </li></ul></ul><ul><ul><li>State of Texas </li></ul></ul><ul><li>Legislation Addressing Obesity in Texas </li></ul><ul><ul><li>Texas SB 2577 </li></ul></ul><ul><li>Ideas for your state </li></ul>
Prevalence and Trends <ul><li>Nearly one-third of US adults are obese (BMI > 30 kg/m2) 1 </li></ul><ul><ul><li>Prevalence has more than doubled in 46 years (13.3% to 30.9%) 1 </li></ul></ul><ul><li>Nearly 5% of US adults are morbidly obese (BMI 40) 1 </li></ul><ul><ul><li>Prevalence of morbid obesity has doubled in 12 years (2.9% to 4.7%) 1 </li></ul></ul><ul><li>17% of children 6-19 years of age are overweight 4 </li></ul><ul><ul><li>Overweight adolescents have a 70% chance of becoming overweight or obese adults 5 </li></ul></ul>Normal Weight (BMI 18.5 to 24.9) Obese (BMI 30 to 34.9) Overweight (BMI 25 to 29.9) 2 1 1 1 1,3 1. Bannerman. CDHC Solutions . 2006. 2. Department of Health and Human Services. 2007. 3. American Obesity Association. 2007. 4. Ogden, et al. Gastroenterology 2007. 5. Department of Health and Human Services. 2007. Severely Obese (BMI 35 to 39.9 ) Morbidly Obese (BMI 40 or more)
1999 Obesity Trends* Among U.S. Adults BRFSS, 1990, 1999, 2008 2008 1990 No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30% Ref: CDC U.S. Obesity Trends 1985–2008 http://www.cdc.gov/NCCDPHP/dnpa/obesity/trend/maps/index.htm **BRFSS= CDC’s Behavioral Risk Factor Surveillance System 2000 (*BMI 30, or about 30 lbs. overweight for 5’4” person)
Medical Complications of Obesity Pulmonary disease abnormal function obstructive sleep apnea hypoventilation syndrome Nonalcoholic fatty liver disease steatosis steatohepatitis cirrhosis Coronary heart disease Diabetes Dyslipidemia Hypertension Gynecologic abnormalities abnormal menses infertility polycystic ovarian syndrome Osteoarthritis Skin Gall bladder disease Cancer breast, uterus, cervix colon, esophagus, pancreas kidney, prostate Phlebitis venous stasis Gout Idiopathic intracranial hypertension Stroke Cataracts Severe pancreatitis www.obesityonline.org
Why? Obesity Rates Trends <ul><li>Americans consume an average of 300 more calories per day than they did 25 years ago and eat less nutritious foods; </li></ul><ul><li>Nutritious foods are significantly more expensive than calorie-dense, less nutritious foods; </li></ul><ul><li>Americans walk less and drive more -- even for trips of less than one mile; </li></ul><ul><li>Parks and recreation spaces are not considered safe or well maintained in many communities; </li></ul><ul><li>Many school lunches do not meet nutrition standards and children engage in less physical activity in school; </li></ul><ul><li>Increased screen time (TV, computers, video games) contributes to decreased activity, particularly for children </li></ul><ul><li>Adults often work longer hours and commute farther. </li></ul>
STATE-BY-STATE ADULT OBESITY RANKINGS –from the “F as in Fat” 2008 issue report <ul><li>STATES with Highest Obesity Rankings </li></ul><ul><ul><li>1: Mississippi;2: West Virginia; 3: Alabama; 4: Louisiana; 5: South Carolina; 6:Tennessee; 7: Kentucky; 8 (tie): Arkansas; Oklahoma; 10: Michigan </li></ul></ul><ul><li>Honorable Mention States: Glass Half Empty- Higher Obesity Rank </li></ul><ul><ul><li>11: (tie) Georgia; Indiana; 13:Missouri; 14: Alaska; 15 Texas 16: North Carolina 17: Ohio;18. Nebraska; 19. Iowa 20: South Dakota; </li></ul></ul><ul><li>Middle of the Pack: Glass Half Full/Half Empty </li></ul><ul><ul><li>21: (tie) Delaware, North Dakota; 23: Kansas; 24:Pennsylvania; 25:Wisconsin; 26: Illinois; 27 (tie) Maryland, Virginia; 29: Oregon; 30:Minnesota; </li></ul></ul><ul><li>Honorable Mention States: Glass Half Full- Lower Obesity Rank </li></ul><ul><ul><li>: 31: Idaho; 32: Washington; 33: Wyoming; 34: Maine; 35: (tie) Nevada, New Hampshire, 37: New York; 38 (tie) Arizona, Florida, New Mexico </li></ul></ul><ul><li>STATES with Lowest Obesity Rankings </li></ul><ul><ul><li>41: California; 42 New Jersey; 43: District of Columbia; 44: Utah 45:Montana; 46: Rhode Island; 47:Vermont: 48: Massachusetts; 49:Connecticut; 50: Hawaii; 51: Colorado </li></ul></ul>Trust for America's Health 2007 report www.HEALTHYAMERICANS.org
Direct Cost of Chronic Diseases in the United States 1,2 Direct Cost ($ Billions) Type 2 Diabetes *Adjusted to 1995 dollars. Obesity Coronary Heart Disease Hyper-tension Stroke $18.1 $18.4 $38.7 $51.6 $53.2 1. Wolf et al. Obes Res 1998. 2. Hodgson et al. Med Care 1999.
Prevalence Rates in the Hispanic Population 1 out of 3 Hispanic Adults in Texas is Classified as OBESE
Texas State Rankings for 2008 Trust for America’s health 2008 report www.HealthyAmericans.org 2005 – 2007 average Percentage of state population per category *Only 45.2% meet recommended Physical Activity Level #15 in Adult Obesity at 27.2% 64.1% overweight and obesity 1 #6 in Child Obesity at 19.1% Ages 10-17 2 #11 in Diabetes at 8.8% #27 in Hypertension at 26.9% 3 #8 in Adult Physical Inactivity at 28.1% 4 Obese High School Students 15.9% 5 Overweight HS Students* 15.6% 6
The Cost of Obesity in Texas <ul><li>According to the Texas Comptroller’s Report on Obesity (2007) </li></ul><ul><ul><li>Cost of obesity to Texas employers in 2005 was $3.331 billion </li></ul></ul><ul><ul><li>By 2025 estimated to be $15.845 billion annually. </li></ul></ul>Obesity Costs to Texas Private Businesses and Insurers
Texas Obesity Legislation <ul><li>SB 2577 – Coverage of bariatric surgery for state employees </li></ul><ul><li>SB 395 – Establishing an early childhood health and nutrition Interagency council </li></ul><ul><li>S.B. 870 expanded the duties of the council and TDA relating to health wellness, and prevention of obesity and the establishment of an obesity prevention pilot program. </li></ul><ul><ul><li>Creates an evidence-based public health awareness plan. </li></ul></ul><ul><ul><li>Coordinates to establish a pilot program designed to decrease the rate of obesity in child health plan program enrollees and Medicaid recipients, improve the nutritional choices and increase physical activity levels of child health plan program enrollees and Medicaid recipients, and achieve long-term reductions in child health plan and Medicaid program costs incurred by the state as a result of obesity. </li></ul></ul><ul><li>HB 4630 – Relating to state employee wellness program </li></ul><ul><ul><li>Creates an online questionnaire for state agency heads to report information, including: </li></ul></ul><ul><ul><ul><li>the agency policy on leave time for employees to complete a health risk assessment; </li></ul></ul></ul><ul><ul><ul><li>the agency policy on leave time for employees to receive an annual physical examination; </li></ul></ul></ul><ul><ul><ul><li>the agency policy on providing employees time during the workday to exercise; and </li></ul></ul></ul><ul><ul><ul><li>whether the agency has a wellness coordinator or council. </li></ul></ul></ul>
Texas Bariatric Surgery Legislation <ul><li>SB 2577 Texas Bariatric Surgery Coverage for State Employees </li></ul><ul><li>Bill Text: relating to bariatric surgery coverage for state employees. </li></ul><ul><li>BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF TEXAS: </li></ul><ul><li>SECTION 1. Subchapter E, Chapter 1551, Insurance Code, is amended by adding Section 1551.225 to read as follows: </li></ul><ul><li>Sec. 1551.225. BARIATRIC SURGERY COVERAGE. (a) The board of trustees shall develop a cost-neutral or cost-positive plan for providing under the group benefits program bariatric surgery coverage for employees eligible to participate in the program under Section 1551.101. </li></ul><ul><li>(b) The board of trustees may adopt rules as necessary to implement this section. </li></ul><ul><li>SECTION 2. The board of trustees of the Employees Retirement System of Texas shall implement the plan required by Section 1551.225, Insurance Code, as added by this Act, as soon as practicable, but not later than September 1, 2010. </li></ul><ul><li>SECTION 3. This Act takes effect September 1, 2009. </li></ul>
Bill Details <ul><li>SB 2577 gives the Employee Retirement System of Texas (ERS) the ability to add Bariatric Surgical Procedures to the ERS health plan. </li></ul><ul><li>The bill directs ERS to produce a bariatric coverage policy that would be cost neutral or cost positive to the plan. </li></ul><ul><li>This allows ERS the opportunity to take direction from the Legislature on the important issue of obesity in Texas by allowing state employees to have the same options that a majority of Texas employers, CMS, and Medicaid recipients in Texas and 45 other states have. </li></ul><ul><li>Fiscal Impact to the state: Neutral to Positive </li></ul>
How to Achieve Cost-Neutral/Cost-Positive <ul><li>ERS reports that in order to achieve cost-neutral or cost-positive results, some examples of potential benefits designs would include, but not be limited to: </li></ul><ul><ul><li>availability to employees who have been covered under the HealthSelect portion of the GBP continuously for 5 years prior to the surgery; </li></ul></ul><ul><ul><li>adherence to guidelines established by the GBP's Third Party Administrator (TPA) including, but not limited to, a Body Mass Index (BMI) of 40 or more, or a BMI of 35 or more with at least 1 comorbidity, and participation in a medically supervised weight loss program and failure at least 1 year prior to the surgery; </li></ul></ul><ul><ul><li>services would be required to be performed at a Center of Distinction, as defined by the TPA; </li></ul></ul><ul><ul><li>benefits would be subject to a separate deductible and co-insurance rate </li></ul></ul><ul><ul><li>expenses would not be applied against the employee's annual out-of-pocket limit; </li></ul></ul><ul><ul><li>benefits would be limited to in-network only and no coverage would be available out-of-network or through a noncontracted facility or physician; </li></ul></ul><ul><ul><li>surgery would only be allowed once in the lifetime of a member. </li></ul></ul>
Senate Bill 395 <ul><li>Little attention paid to early childhood population </li></ul><ul><li>SB 395 establishes the Early Childhood Health and Nutrition Interagency Council </li></ul><ul><li>Council will engage the 7 regulatory agencies that have a role in the regulation and management of early childhood settings in TX </li></ul><ul><li>Agencies will work with experts to study best practices for improving early childhood nutrition and create a plan that will provide related recommendations for implementation over a 6 year period </li></ul>
Ideas for State Obesity Legislation <ul><li>19 states set nutritional standards for school lunches, breakfasts, and snacks that are stricter than current USDA requirements. Five years ago, only four states had legislation requiring these stricter standards. </li></ul><ul><li>27 states have nutritional standards for competitive foods sold a la carte, in vending machines, in school stores, or in school bake sales. Five years ago, only six states had nutritional standards for competitive foods. </li></ul><ul><li>Every state has some form of physical education requirement for schools, but these requirements are often limited, not enforced, or do not meet adequate quality standards. </li></ul><ul><li>20 states have passed requirements for body mass index (BMI) screenings of children and adolescents or have passed legislation requiring other forms of weight-related assessments in schools. Five years ago, only four states had passed screening requirements. </li></ul><ul><li>19 states have laws that establish programs linking local farms to schools. Five years ago, only New York had a farm to school program. </li></ul><ul><li>30 states and D.C. have some form of a snack tax. </li></ul><ul><li>Four states -- California, Maine, Massachusetts, and Oregon -- have enacted menu labeling legislation. </li></ul><ul><li>24 states have passed legislation to limit obesity liability </li></ul>
Increase in Healthcare Costs of Obese versus Individuals with BMI < 25 kg/m 2 1 Increase in Cost Compared with Lean Subjects (%) BMI 30-34 kg/m 2 BMI > 35 kg/m 2 1. Quesenberry et al. Arch Intern Med. 1998. HMO Setting: Northern California Kaiser Permanente Healthcare visits Pharmacy Laboratory tests All outpatient services All inpatient services Total healthcare
Treatment Options Comorbidity + - National Institutes of Health et al. http://www.nhlbi.nih.gov/guidelines/obesity/prctgd_c.pdf. Accessed November 5, 2008 <ul><li>* Malabsorptive procedures: Jejunoileal bypass </li></ul><ul><li>Restrictive procedures: Gastric banding, Sleeve Gastrectomy </li></ul><ul><li>Combination procedures: Roux-en Y gastric bypass (RYGB), </li></ul><ul><ul><ul><ul><li>Biliopancreatic Diversion/Duodenal Switch </li></ul></ul></ul></ul>1. Dixon et al. Diabetes Care . 2002. 3. Fisher, et al. Amer J Surgery, 2002. Xenical ® is owned by Hoffmann-La Roche Inc. 2. O ’ Brien et al. Obes Surg . 2006. 4. Wierzbicki, A. Int J Clin Pract. 2006 Meridia ® is owned by Abbott Laboratories, Inc. <ul><ul><li>Diet </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><ul><li>Behavior modification </li></ul></ul>Lifestyle Changes Medications (Alli® OTC, Xenical® and Meridia®) BMI (kg/m ² ) Surgery* 27-29.9 ≥ 30 25-26.9 ≥ 27 35-39.9 ≥ 40 <ul><ul><li>Ineffective over time (5% to 10% EWL, on average) 1,2,3 </li></ul></ul><ul><ul><li>Short-term use not effective (5% to 10% EWL, on average) 1,2,3,4 </li></ul></ul><ul><ul><li>Effective over time (≥50% EWL sustained for 10 years) 2,3 </li></ul></ul>
Weight-Loss Surgery Laparoscopic Adjustable Gastric Banding* vs Gastric Bypass Surgery — Safety * Includes LAP-BAND ® System and other adjustable gastric banding systems. † Published complication rates vary depending upon the institution and how the surgeon diagnoses and defines a particular complication. 1. Parikh et al. J Am Coll Surg . 2006. 2. Chapman et al. Surgery . 2004. Categories LAGB Gastric Bypass Total Complications † 1 9% (n = 480) 23% (n = 235) Major Complications † 1 (Grades III and IV) 0.2% (n = 480) 2.1% (n = 235) Postsurgical Mortality Rate 2 (Short-term) 0.05% (n = 5780) 0.5% (n = 9258)
Impact of Bariatric Surgery on Mortality <ul><li>Within the past several years, studies evaluating the effect of bariatric surgery on mortality have found: 1-6 </li></ul><ul><li>Overall mortality appears to be reduced by approximately 50% </li></ul><ul><ul><li>Mortality reduction is seen with deaths related to myocardial infarction, cancer, and diabetes </li></ul></ul><ul><ul><li>Dramatic decreases in mortality was observed in obese patients (hazard ratios 0.11-0.76) </li></ul></ul><ul><ul><li>Substantial mortality reductions relative to controls were observed in two studies evaluating only LAP-BAND ® System patients (hazard ratios 0.28 and 0.36) 5,6 </li></ul></ul><ul><li>Studies do not allow for conclusions to be drawn about the relationship between the extent of weight loss and mortality </li></ul>1.Christou et al. Ann Surg 2004 2.Flum et al. J Am Coll Surg 2004 3. Sjöström et al. NEJM . 2007 4.Adams et al. NEJM 2007 5. Peeters et al. Ann Surg 2007 6.Busetto et al. Surg Obes Relat Dis 2007
Cost Savings in Surgically Treated vs Conventional Therapy at 5 yrs N=1118. 5-yr follow-up (1986-2002). McGill University Heath Center, Montreal. Sampalis JS. Obes Surg. 2004;14:939-947 Average Cost Per 1,000 Patients for Hospitalization $ (Millions)
Economic Impact of Bariatric Surgery <ul><li>Objective: evaluated private, third-party payer return on investment for bariatric surgery in the U.S using a large, insurance claims database </li></ul><ul><li>N=3651 bariatric surgery patients and matched morbidly obese controls, based on patient demographics, selected co-morbidities and costs </li></ul><ul><li>Analyzed 6 months pre-surgical evaluation and care, surgery, and ~18 months post surgical care </li></ul><ul><ul><li>Included costs incurred from surgical complications </li></ul></ul><ul><ul><li>Some patients’ post surgical claims tracked for up to 5 years </li></ul></ul><ul><ul><li>Costs included payments for prescription drugs, physician visits and hospital services </li></ul></ul><ul><ul><li>Monitored claims for obese patients without surgery over the same period </li></ul></ul><ul><li>Results: insurers fully recovered costs of laparoscopic surgery after 2 years, and within 4 years for open surgery patients </li></ul><ul><ul><li>Between 2003 and 2005, break-even point was reached in 49 months for traditional bariatric surgery, which carries an average cost of $26,000. </li></ul></ul><ul><ul><li>Laparoscopic surgery is a less-invasive version of gastric bypass, with an average cost of $17,000 </li></ul></ul><ul><li>*The study did not address gastric banding </li></ul>Cremieux et al. Am J Manag Care. 2008;14(9):589-596