©

Solving the Overweight/Obesity Management Puzzle

10/22/04

Rosemary Burke, RN, MSRobin F. Foust, BS, PAHM

©

BACKGROUND

• MediCorp Health System– 28 facility healthcare system headquartered in Virginia

• Mary Washington Hospital– Benefits Department– Associate Wellness Program

• Data/Experience– MedPar: 22 cases in 2001 to 147 cases in 2002 for 3

hospitals reviewed in MediCorp’s region– MediCorp: 16 cases many with poor outcomes

• Process for Change.– Zoe Consulting, Inc.– Associate/Member Wellness Program

©

BACKGROUNDMediCorp is not alone but a pioneer in

Solving the Puzzle/Problem One of the chief medical officers for the Division of Health Care

Financing in the Department of Health and Family Services in Wisconsin also approached Zoe Consulting for help…

“We revamped our guidelines in 1999 using the recommendations of the Am Bariatric Soc. , NIH National Heart, Lung, and Blood Institute clinical guidelines and the Clinical guidelines on the Identification, Evaluation and Treatment of Overweight and Obesity in Adults (Arch. Int. Med/Vol 158 Sept 28, 1998).

“We went from 77 approvals in 1997 to more than 300 in 2004, which will likely rise.  We need to find the middle ground to support weight loss through conventional means and provide surgery when appropriate; i.e., the patient can cooperate, is psychiatrically able to participate in pre and post surgery programs, and has acceptable surgical risks”…

©

BACKGROUNDOVERWEIGHT AND OBESE MEMBERS

Based on National statistics and MediCorp Associates’/Members’ research, MediCorp determined the need for work site nutrition and weight management programs in order to educate Associates on health risks and costs associated with obesity. There is a connection with:

• CVD: Heart disease, Hypertension, Diabetes • Certain Cancers; Breast, Endometrial, Prostate • Infertility, complex pregnancies, gestational diabetes, toxemia • Fibroid tumors • Sleep apnea or Pickwickian syndrome • Pulmonary embolus • Distress, anxiety, & depression • Arthritis

©

BACKGROUNDOVERWEIGHT AND OBESITY

• Leading causes of morbidity and mortality– Sedentary Lifestyles– Unhealthy Weights (diets/overweight)– Tobacco Use– Risky drinking (alcohol)

• Consistent evidence that that behavioral risk factors cluster in individuals and populations

• More than ½ of U.S. adults report two or more of the four primary behavioral risk factors

• Progress in effective interventions for modifying these primary risks

Source: Michael Goldstein, MD, and Susan Curry; Addressing Multiple Behavioral Risk Factors in Primary Care; American Journal of Preventive Medicine; August, 2004

©

BACKGROUND

Surgeon General Satcher, MD states: “Overweight and obesity may soon cause as

much preventable disease and death as cigarette smoking. People tend to think of overweight and obesity is strictly a personal matter, but

there is much that communities and employers can and should do to address these problems.”

©

BACKGROUND

PROGRAM TYPES

(choices)

Weight Management,

Obesity with request for Gastric Bypass Surgery Overweight & Obesity Related Disease Treatment

©

YEARLY COST PER PERSON BY PROGRAM TYPE

$662

$5,000

$40,000

$0

$5,000

$10,000

$15,000

$20,000

$25,000

$30,000

$35,000

$40,000

$45,000

Annual Cost

Weight ManagementProgram $662

Over weight & ObesityRelated Diseases$5,000Gastric BypassSurgery $40,000

©

BACKGROUND OBSTACLES FOR ASSOCIATES

A survey of 235 Associates determined what obstacles they face in maintaining a healthy lifestyle.

0%

5%

10%

15%

20%

25%

30%

35%

Hectic Work Schedulen=47

Lack Time to Excerisen=77

Wt Loss Center NotConvenient n=26

Food Choices n=14

Healthy Eating Expensiven=10

Lack of EducationClasses n=42

Lack of Support Groupsn=19

47

77

2614

10

42

19

©

POLICY REVISION

PREMISE

Carrier’s policy was not effective,

Something had to change

©

POLICY REVISION OBJECTIVES

• Help achieve optimal outcomes for patients who have gastric bypass surgery– Improve Associate Satisfaction– Improve Human Performance (Productivity)– Improve Health Status Outcomes

• Reduce the number of inappropriate surgeries by applying prudent criteria for coverage as indicated in the scientific literature

• Ensure optimal quality of care is afforded gastric bypass surgery candidates

• Achieve optimal health status, health care, and financial outcomes

©

POLICY REVISION• Total document is over 50 – 500 pages (with or w/o guidelines)• Actual Policy is 2 pages front & back• Twenty (20) criteria for approving coverage

– Procedures– CPT, ICD-9, DRG,– BMI– Other

• Unique criteria not in standard policies– Mandatory 6 month participation in Associate Wellness Weight

Management Program pre and post surgically – if approved and/or proceed with surgery

– Psychological assessment– Sleep Apnea lab

• Backed by research & published guidelines (20 referenced sources)• Periodically review and update

©

COVERAGE• Coverage differential for use of Center of Excellence• Coverage for abdominoplasty or panniculectomy• 100% covered for AW Weight Management and

other policy required services• If proceed with surgery; coverage follows benefit

plan based on 3 levels• If Associate/Patient does not comply with

requirements then all costs will be payroll deducted and associate is responsible for all charges – Weight Loss Program and/or Surgery

©

THE POLICYIN SUMMARY:

• Patient must file for approval through the Benefits/Associate Wellness Program (AWP)

• Patient must meet clinical guidelines for approval• Patient must comply with all procedures outlined by the

policy and the Associate Wellness’ Weight Management program before approved for surgery

• Once the appropriate forms are filed and coverage approved, the AW – Weight Management program will work with the patient’s physician to refer the patient to a designated COE

• AWP continues working with the patient for at least 6 months post surgery both by phone and in person

©

Options for Program Delivery to Support Employer Policy Revision

-- and -- Policy and Program Implementation

– Internal monitoring and program delivery like the MediCorp program design through AW -- which is presented next -- or,

– External contracting through various program providers, or

– Combination, and/or custom program design

©

MEDICORP’S PROGRAM• PROGRAM DESIGN:

– Basic: • Weight Loss

– Monitoring and Support through Associate Wellness (AW)– Weight Watchers for group support ongoing & in addition to AW

counselor meetings– Counselors apply behavioral change communication techniques

to support lasting change• Obesity Management – Gastric Bypass Surgery

– Compliance with Policy– Monitoring and Support through Associate Wellness (AW)– Weight Watchers for group support ongoing & outside AW– Approval For Coverage

» Yes: Surgery with 6 months post surgical program» No: Coverage for surgery denied

– Goal:• To educate participants to manage their weight through:

– Improved nutrition and increased activity, – Develop positive lifestyle behaviors, and – Meet their individual weight loss goals.

©

MHS PLAN• Implement Weight Loss Program for Associates with 100 pounds

excess weight or have a BMI of 35 or more with co-morbidities

• Implement Weight Watchers at Work Program for Associates with moderate excess weight

• Implement an alternative weight loss program for Associates seeking Gastric Bypass Surgery

• Developed and implemented Program and Data Base System– Monitor patient/associate’s progress – Initial Assessment,

Reassess every three months – Monitor compliance to policy approval criteria– Programs consist of:

• Lifestyle changes, • Proper nutrition, and • Physical Activity (exercise)

©

PROGRAM ENTRY

SURGICAL CANDIDATES

WEIGHT MANAGEMENT

SURGERY APPROVED

ASSESSMENT

RISK&

LEVEL OF CARE

GOAL SETTINGSHORT TERMLONG TERM

COMPLIANT 6 Month Pre-Surgical Plan

YES NO

Y N

ELECTS SURGERY

6 Month Post Surgical &

Weight Management GRADUATION

GOAL ACHIEVEDPROGRAM

REPORTING & EVALUATION

EDUCATION:Carekits/other

materials mailed

Surgery Denied

ACHIEVE HEALTHY WEIGHT

COMPLIANCE PROGRAMS &

ELEMENTS

GROUP SUPPORT SESSIONSi. E , Weight Watchers, or

other

©

Screen Shots

©

Screen Shots

©

Screen Shots

©

PROGRESS REPORT

• Associates confirming improved overall health– More energy and stamina– Decreased medications– Decreased shortness of breath with physical activity– Decreased joint pain– Increase in confidence and “Total Quality of Life”– Decrease in time off from work and health claims

©

ASSOCIATE PROGRESS REPORT• 45 presently in Weight Management • 52 enrolled in Weight Watchers at Work • 235 have completed the program since 2000• MediCorp has lost a total of 5730 pounds since

9/2000• Documented 9 surgeries avoided since program

began; or $360,000 saved. (average cost of $40,000/case with no complications)

• 3 current candidates requesting Gastric Bypass surgery: – Wt loss from 45-73 pounds per person in <1yr

• 1 had a gastric bypass (Self-pay) after 31# loss in 8 weeks in program. Now a spokesperson to stay in AW program -- not surgery

©

92 Associates Who Have Lost As Little As 15% of Their Total Body Weight Experienced Improvement

in Overall Health.

Overall Improved Health

0% 20% 40% 60% 80% 100% 120%

Self Esteem

Medications

Improved Breathing

Blood Pressure

Cholesterol

Energy Level

Lost Time

Percentage of Associates with Improved Health

n=43n=92

n=30n=38

n=79n=21

n=84

©

Where Are We Now?

MAINTAINED WEIGHT LOSS (6 Mo. To 3+ Yrs)

Lost 15% and over of Body Weight

44%

Lost 5-14% of Body Weight

27%

Quit Program18%

No Weight Loss or Gained Weight

11%

Lost 15% and over of Body WeightLost 5-14% of Body Weight

Quit ProgramNo Weight Loss or Gained Weight

n=14n=59n=24

n=36

N=135 total

©

NEXT STEPS

• Increase promotion of programs:

• Campaign for membership – membership drives, hospital orientation, Great American Weigh-In, Wellness Fair • Advertise – ICP mail, posters, Quick Takes • Offer non-food incentives for joining the program

• Increase number of mentors

• Continued support upon completion of program (re-assess every 6 mo.)• Implement a Weight Management Team consisting of Weight Management Staff, F&N, Dietician, Assist, PM&R, Orthopedic, Endocrinologist• Increase number of Weight Watcher Meetings to 4 each week

©

SUCCESS STORIES60 yr old male lost 170 # over 15 months

“Made me more productive at work and home. Improved my relationships with family.”

40 yr old female lost 40 # in 6 months“I can walk without being winded. I can ride amusement rides, not sit on the bench.”

30 yr old female lost 100 # in 11 months“I never missed a meeting. This has changed my life forever. I am no longer out of control.”

50 yr old female lost 75# in 12 months“I am down from 7 to 2 pills a day.”

©

CONCLUSION

Overweight/Obesity negatively impacts: Health Life at home and at work 92% of on the job injuries at MHS Cost and Use of health insurance Our management survey revealed -- & weight management Associates confirmed -- that obesity decreases productivityWORK PLACES CAN MAKE A DIFFERENCE

©

The Surgeon General is right “… there is much that communities and employers can and should do to

address these problems.”

©

THANK YOU

Rosemary Burke rosemary.burke@medicorp.org

Robin F. Foust803-324-8626

robinzoe@comporium.netwww.zoeconsulting.com

©

References:

1. Obesity Statistics, National Institute of Diabetes & Digestive & Kidney Diseases and WebMD.com

2. O’Brien PE, Dixon JB, The Extent of the Problem of Obesity, AMJSurg. 2002 Dec; 184(6B):4S-8S

3. US Department of Health and Human Services; Centers for DiseaseControl and Prevention, 2002

4. Finkelstein EA, Fiebelkorn IC, Wang G, State Level Estimate of Annual Medical Expenditures Attributed to Obesity Jan 2004; 18-24

5. Centers for Disease Control and Prevention, Prevalence of Overweight and Obesity Among Adults; US 2004

6. Monahan, b, AVP, Workforce Strategies, Fighting Obesity is the Key to Health and Productivity Management Study, AON 2004

7. Palmer and Cay Consulting Group “Policy Criteria and Procedures for Gastric Bypass Surgery Approval” Aug. 2003

8. US Surgeon General, Prevent and Decease Overweight and Obesity 2001

9. US Depart. Of Health and Human Services NI Pub. No. 01-4006 Dec 2001