Does Paying Cash Get You Better Obesity Care Outcomes?

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Despite current rates of obesity, classification of obesity as a disease, and the known comorbid (and costly) associated conditions, access to effective nonsurgical and surgical care to treat obesity remains a challenge for many.

There is still a prevailing opinion that obesity is exclusively a “lifestyle disease,” meaning that: “It’s your fault for overeating and not exercising enough.” This thought process continues to influence insurance coverage nationwide. Even though it’s been classified as a disease, there still seems to be this pervasive opinion that, despite its disease classification, by offering insurance coverage or assistance, you are taking away personal responsibility regarding management and treatment. “Just go on a diet, exercise and stay committed,” is the sort of stance taken by many insurance companies and health practitioners. This ongoing premise persists, despite a 2014 memo from the U.S. Office of Personnel Management, which mandated coverage of 2.7 million federal employees, specifically for obesity pharmacologic treatment.

A May 2017 report in the journal Obesity examined whether paying for obesity treatment out-of-pocket (which is not infrequent, given current insurance company policies regarding non-surgical treatments) yielded better care and outcomes, compared to similar practices covered by insurance. The thrust of the research aimed to see if when you pay for care related to obesity from your own cash stash, does it somehow inspire you to be more compliant and more committed compared to individuals whose insurance foots the bill?

The subjects for this study were participants in the Wake Forest Baptist Health Weight Management Center (WMC), enrolled in either the By Design OPTIFAST or By Design Essentials programs, sometime during January 2013 through June 2015. The OPTIFAST program was a 52-week program with one or more visits with a doctor monthly, one visit with a dietician (on average) monthly, four visits with a behaviorist during the year, 10 supervised exercise sessions, and a goal of about two to three pounds of weight loss weekly. The Essentials program lasted 24 weeks, offered four doctor visits, five dietician visits, one behaviorist visit, no supervised exercise sessions, and an average weight loss target of about one to two pounds per week. Both programs offered weekly behavioral group sessions.

The enrollees were grouped into “covered by insurance,” and had to only pay $246 for the Essentials program or $345 plus replacement meal costs for the OPTIFAST program versus the “cash” group, which paid $480 plus the cost of four medical visits for the Essentials program or $2,730 plus meal replacement costs for the OPTIFAST program. Electronic medical records provided baseline weight (BMI), length of participation (a percentage of all groups dropped out), and weight-loss data. The researchers also looked at age, socioeconomic status, and sex.

Before we get to the weight-loss comparisons, it’s important to take note of some very interesting observations. First, this was not a randomized trial. In fact, all the insured participants worked for Wake Forest Baptist Health. Self-pay subjects were mostly white (as were the employees), lived in neighborhoods of predominantly college-educated members, and had higher mean per-capita incomes. Insured subjects were younger and had slightly lower baseline BMIs compared to cash-paying participants. Most of the participants in the two groups were women. The overall dropout rate for paying and non-paying individuals was similar, 15.2 percent. Self-pay patients had a 5 percent higher dropout rate, mostly in the Essentials program.

In terms of weight-loss outcome, both groups in both programs achieved similar results. Total weight loss was on average about 13 pounds. Percent of subjects who achieved 5 percent or more weight loss at the end point, was 78.7 percent in the self-pay group versus 82.4 percent in the uninsured group. For 10-percent or more weight loss at the end point, in the insured group 54.8 percent had success versus 59.9 percent of individuals in the self-pay group.

From a pure weight-loss outcome, this report suggests that whether insurance pays for the treatment program, or you pay out-of-pocket, individuals will lose similar amounts of weight. If we look a bit more closely at some of the variables found, the insured group was younger and had lower BMI rates (though still obese) on average compared to the pay-cash group. This suggests that intervention may occur sooner if you have coverage for treatment of obesity. It’s also clear that you have to have disposable income to afford payment for an extended weight-loss program if you’re not covered by insurance. Both of those have to be considered barriers to care for the very people who may be in dire need of treatment options for this disease. It may be incorrect to assume that motivation “is higher” when you work harder, i.e. pay for a treatment program versus being given access to covered treatment. The commitment and end-point rates in this study were similar for cash and insured participants. The notion that “we have to work hard to earn it” may not apply when seeking help for a chronic, quality-of-life issue like obesity. More people than we realize may simply be defeated by a lack of access to affordable treatment .

The researchers suggest that lack of nationwide insurance coverage for comprehensive, long-duration treatment of obesity is a major barrier to individuals with clinical obesity. Despite some coverage for obesity counseling by the Centers for Medicare and Medicaid Services, there is still not sufficient access for most individuals in all age groups. Given rates of obesity, there is a huge and persistent insurance gap for nonsurgical treatment of obesity, though insurance coverage for surgical interventions has improved (qualifying teens still struggle to get approved).

Despite the limitations of the study, it’s clear that we need to fast-track treatment access and coverage for patients diagnosed with obesity.

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